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NERVE WOUNDS
SYMPTOMATOLOGY OF PERIPHERAL XERVE
LESIONS CAUSED BY WAR WOUNDS
J. TINEL
ANCIEN CHEF DE CLINIQUE 1.1 DE LABORATOIRE DL.VI A SALPETRIERE
PREFACE BY
PROFESSOR J. DEJERINE
AUTHORISED TRANSLATION LV
FRED ROTHWELL, B.A., Lond.
REVISED AND EDITED BY
CECIL A. 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
EDITOR'S INTRODUCTION
My object in making Dr. Tinel's book available in English has been to
fill a very definite gap in the literature of peripheral nerve lesions. I am,
of course, aware that there are excellent manuals on the subject by British
authors, but none of them appears to me to cover the ground so fully, so
authoritatively, and so originally as Dr. Tinel's.
The continental clinic system makes it possible for the clinician to
investigate a far larger number of cases than under our own individualistic
methods. I hope that, with the return of peace, the clinic system, intro-
duced in a modified form by my colleague, Mr. James Berry, at the Royal
Free Hospital, will be continued and expanded.
I have endeavoured to adhere closely to Dr. Tinel's text. If, how-
ever, I have failed to reproduce his meaning, the responsibility is certainly
mine, as his book is most lucidlv written.
I have throughout preserved the term " griffe " rather than use the
rather doubtful translation " claw," and in one or two other cases where
translation did not appear to be helpful, I have retained the original word.
I wish to thank Mr. Rothwell for great help in the revision of the proofs.
CECIL A. JOLL.
WlMPOLE StRIET, W.
October, 191 7.
) Muscular tone. — The study of muscular tone is very important, as
J. and A. Dejerine and Mouzon have shown.
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,
whereas complete interruption of
the nerve after some time causes its
total disappearance.
Nerve irritations, on the other
hand, are not accompanied by very
marked hypotonia ; it is frequently
less marked than in simple com-
pressions.
On palpation, muscular tone
may be recognised by the greater
or less flaccidity of the muscular
bellies.
It may more readily be studied by
causing the antagonistic muscles to contract ; then, if tone is maintained,
a slight synergic swelling of the paralysed muscles is perceived.
The degree of tone is even better recognised by the attitude of the
limb, for the disappearance of tone somewhat intensifies the paralytic
Fig. 13. — Complete hypotonia in inter-
ruption of the musculo-spiral nerve.
FlG. 14.— Return of muscular tone 73 days after suture, in the preceding case.
attitude. For instance, in musculo-spiral paralysis from simple com-
pression, the hand remains hanging down at the end of the fore-arm,
but if slight pressure is given to the hand, tending further to accentuate
the flexion of the wrist — this accentuation is found to be possible since the
hand was not flexed to its full extent — and if the pressure exercised is
suddenly released, the hand rises slightly, elastically, owing to some
CLINICAL EXAMINATION OF A NERVE 23
remaining muscular tone. In complete section of the musculo-spiral,
however, flexion of the hand after a few weeks reaches the maximum
permitted by the articular ligaments.
Disappearance of tone, therefore, is an important sign in favour of
complete interruption of the nerve. (J. and A. Dejerine and Mouzon.)
It must, however, be noted that the prolonged inaction of a muscle,
even in a certain number of functional paralyses, may be accompanied by
hypotonia, which in time becomes considerable.
(c) Mechanical contractility of the muscle. — It is important to dis-
tinguish muscular tone from idio-muscular contractility. Percussion of a
normal muscle produces a local and momentary swelling of the percussed
muscular fasciculi, and that this is a genuine contraction is shown
by more or less extended movements. This is the idio-muscular
reflex.
Idio-muscular reflexes are always intensified in peripheral-nerve lesions,
even though there is considerable hypotonia or even complete atonia.
This intensification of the mechanical contractility of the paralysed
muscle is, as we shall see, comparable to the intensification of the con-
tractility of the muscle under the galvanic current (galvano-tonus), when
excitability of its nerve at the motor point has disappeared. Like con-
traction of the paralysed muscle under the galvanic current, the contrac-
tion provoked by percussion is slow. This amplitude and this slowness of
contraction often permit a diagnosis of paralysis to be made. It con-
stitutes a veritable " mecano-diagnosis " (Andre-Thomas). This is Sicard's
" mechanical myo-diagnosis."
In a word, it may be said that, in a paralysed muscle, contractility from
excitation of the nerve, whether voluntary or electrical, diminishes or
disappears, whereas the contractility peculiar to the muscular tissue itself
is intensified ; the former is rapid and short, the latter is tardy in appear-
ance and slow in its 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 and even the absolute insensibility of the muscle
to pressure is one of the clear signs of complete interruption. (J. and
A. Dejerine and Mouzon.)
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
nerve under pressure.
This pain may be extremely acute, rendering impossible all mobilisation
or massage.
It may exist even when the muscle is not paralysed ; then pressure on
24 NERVE WOUNDS
the muscle frequently causes very painful though fleeting contractions and
cramps. Voluntary contraction also causes violent pains, to such an extent
that false paralyses may be noticed, resulting from immobilisation of the
muscle through fear of pain.
Nerve pain in the muscles is very often accompanied by fibrous
contractions.
(e) Fibrous contraction of the muscles. — Whereas compressions and
especially nerve sections are accompanied by hypotonia, flaccidity and pro-
gressive lengthening of the muscles; nerve irritation, on the other hand, is
almost always accompanied by muscular contraction with fibrous trans-
formation.
A modification in the consistency of the muscle is then found ; it
becomes hard, fibrous, painful and adherent to the neighbouring tissues ;
certain muscles end by acquiring an almost woody consistence.
At the same time, this muscle has a tendency to contract. These
muscular contractions progressively limit the excursion of the corresponding
joint, modify and so far restrict the paralytic attitude as sometimes to
mask it ; 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. The fibrous griffes of the
ulnar and the median, the contraction of the posterior muscles of the leg,
likely to lead to pes equinus and to necessitate tenotomy, are so many
instances of these nerve contractions.
The muscular examination must always end in a search for fibrous
contraction, by investigating the passive movements of the corresponding
joints.
All limitation of articular movement is 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 with
paralysis of these nerves.
One must naturally avoid confusing nerve muscular contraction with
articular lesions and especially with the cicatricial contractions and
adhesions of muscles or tendons, approximately ending in almost the
same attitudes and the same limitation.
(/) Muscular contraction and hypertonia. — Lastly, certain cases of
nerve irritation, mostly slight, are accompanied by a state of muscular
hypertonia, sometimes going as far as real contraction ; thus we meet
with attitudes that are permanent and paradoxical, in some way the
opposite of paralytic attitudes, reducible with difficulty and even at times
almost impossible to overcome. The pain in the muscles under pressure,
intensification of the idio-muscular reflexes, the sensory, vaso-motor or
secretory disturbances met with in these cases, particularly the increase
of the secretion of sweat (Babinski) show clearly the irritated condition of
the nerve fibres.
CLINICAL EXAMINATION OF A NERVE 25
Almost always, however, in these contractions, especially when per-
manent, we meet with an important functional factor ; they are certainly
emphasised and intensified by inaction of the patient.
V.— OBJECTIVE EXAMINATION OF THE INTEGUMENTS
AND SUPPORTING TISSUES. 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-
Fig. 15. — Cutaneous disturbances in a case of nerve irritation. (Note the smoothness
of the fingers of the left hand and the disappearance of the cutaneous folds.)
turbances are either absent or very slight in almost all cases of nerve
interruption or simple compression.
On the other hand, they are almost constant in nerve irritations.
(a) Integuments. — Examination of the integuments is bv far the most
important and may reveal very different disturbances.
Glossy skin is the most frequent ; disappearance or diminution of the
cutaneous 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 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
and dull colour, the disappearance of the cutaneous folds, the fibrous con-
sistence of the integuments which are adherent to the underlying tissue
and difficult to mobilise: these disturbances, always more pronounced at
the extremities, give the hand and foot a waxy and fixed aspect which is
altogether characteristic.
(b) Sweat reactions. — The skin of paralysed hands and feet is 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 all, in neuralgia,
occurring without complete paralysis.
Dryness of the skin is very important ; it is found in most cases or
nerve section and is sometimes accompanied by a fine branny desquama-
tion which clearly delineates the cutaneous topography of the nerve. But
it is also very pronounced in certain cases of nerve irritation, especially in
severe cases with paralysis, where there is also found an abundant cutaneous
desquamation in broad scales. The skin, thickened and indurated, assumes
quite a rough, scaly, fish-skin appearance.
We 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. (Claude and Chauvct, Jumentic.)
CLINICAL EXAMINATION OF A NERVE 27
(f) Vaso-motor disturbances. — Vasomotor disturbances arc practically
inevitable in all nerve lesions.
In some cases we find pallor of the integuments, along with the
dryness and thickening of the skin. It is mainly found on the palms of
the hands and the soles of the feet, where the thickness of the integu-
ments and their dull tint seem to mask the colouring of the deeper
planes.
Cyanosis and redness of the integuments are far more frequent.
Cyanosis more especially indicates vaso-motor paralysis, acting upon
the vaso-constrictor apparatus. It is exaggerated by a dependent position
and by cooling ; it rapidly diminishes and disappears if the limb is placed
in an elevated position.
We need only compare the cyanosis and the pallor produced in the
healthy limb and in the paralysed one, when placed alternately in
dependent and elevated positions, to see that the paralysed limb becomes
cyanosed more quickly and pales more rapidly than the healthy limb.
The white spot, likewise produced by pressure of the finger, disappears
more quickly on the paralysed limb.
In a word, these phenomena show the loss of tone of the vaso-con-
strictor muscles in the paralysed region.
In certain conditions, however, one may notice an apparently para-
doxical phenomenon. If the cyanosed limb is not in too dependent a
position, and the venous pressure not too great, vigorous rubbing with the
nail often produces a white streak which slowly enlarges and may persist
for one or two minutes. On the sound limb, however, the narrow white
streak obtained by the nail rapidly disappears and gives way to the usual
red streak. Probably this paralytic white streak results from the slow and
prolonged contraction of the vaso-constrictor muscles, brought out by
mechanical excitation. Like the other muscles, the paralysed muscular
fibres of the small vessels seem to have lost their nervous excitability,
whilst their idio-muscular contractility has become intensified.
On the other hand, redness of the skin is found especially in neuritic or
slight neuralgic irritations, without paralysis. It is particularly marked in
causalgia, and usually coincides with increase of the sweat secretions.
Probably it corresponds to active vaso-dilatation.
Redness or cyanosis of the skin may in certain cases reach an extreme
degree ; for instance, we find the index finger in certain irritations of the
median, and the little finger in certain lesions of the ulnar, assume a red,
wine-coloured, cedematous and shiny aspect ; the fingers are covered with
chilblains. The special susceptibility of the paralysed extremities to
chilblains must also be remarked.
GEdema is sometimes found in nerve interruptions ; for the most part it
would seem to be only the intensified swelling by stasis observed in
prolonged dependent positions ; this is an oedema of posture and disuse.
28
NERVE WOUNDS
Along with cyanosis it sometimes produces appearances recalling that of the
" succulent hand " in syringomyelia.
Then again, oedema is evidently the result of nerve irritation j it may
reach a considerable degree ; in these cases we have seen it rapidly
disappear as the result of surgical intervention.
Finally, it will not be forgotten that oedema, like cyanosis, often
results from vascular lesions associated with nerve lesions ; these must be
systematically investigated.
In all these cases, the distribution of the vaso-motor disturbances is
exactly spread over the cutaneous region of the affected nerves. Claude
and Chauvet justly remark that this vascular
topography is often more precise and exact,
more in conformity with the anatomical region
of the nerve, than the distribution of the sensory
disturbances.
(d) Ulceration. — Genuine ulceration is very
rare in peripheral nerve lesions. Almost always
we can find the exciting cause.
For instance, these are secondarily ulcerated
bullous lesions, that have appeared after too
hot a bath or after a too intense galvanic bath ;
they have the characteristics of burns, and
indeed they doubtless are burns appearing over
a region of disturbed nutrition, or else ulcera-
tion caused by the pressure of an apparatus,
or again we are dealing with a perforating
ulcer on the sole of the foot, one which has
developed as usual at the site of a corn and has
certainly been caused by pressure in walking.
In all cases these lesions, though rare, are scarcely ever spontaneous ;
the nerve lesion appears only as a predisposing cause by reason of the dis-
turbances in nutrition which it calls forth. They would seem to occur
both in cases of complete section and in nerve irritation.
(/) Thermal disturbances. — On the paralysed limbs there may be re-
marked a lowering or an elevation of the local temperature.
Actual persistent rise of the local temperature is found only in certain
slight nerve irritations, with permanent vaso-dilatation and redness of the
skin.
On the other hand, lowering of the temperature is very frequent.
But this is really an artificial cooling, resulting, on contact with the air,
from a less active circulation. The cooled limb slowly becomes warm in
bed or if it is wrapped in wadding ; it almost regains its normal tempera-
ture but again cools more rapidly than the sound limb as soon as the
surrounding temperature falls.
Fig. 17. — Ulceration in a case
of complete interruption of
the posterior tibial nerve.
CLINICAL EXAMINATION OF A NERVE
29
Marked and persistent cooling of a limb mainly results from the
vascular lesions associated with the nerve lesion. It is then accompanied
by chronic cyanosis, by oedema and the progressive fibrous infiltration
which characterise ischemic paralysis.
(f) Skin appendages. — Hypertrichosis is almost constant in all nerve
lesions.
The nails are specially affected. Whilst, on the one hand, in simple
sections or nerve compressions there is found only a simple transverse
groove, changing place with the growth of the nail and thus marking the
date of the paralysis ; on the other hand, in nerve irritations there are found
serious trophic affections of the nails ; they are striated, split, laminated,
thinned at the edges, curved like claws or deformed into the shape of a
watch glass.
Frequently too they are atrophied, smaller than those of the opposite
side, and this diminution, associated with cutaneous and bony atrophy,
ends in a sort of tapering conical appearance of the last phalanx of the
fingers.
(g) Aponeuroses, tendons, synovial sheaths, bones and articulations. —
The trophic disturbances of nerve irritation also reach the deeper planes.
The thickened and contracted palmar fascia gives the impression of
cords, to a certain extent reminding one of Dupuytren's disease ; the
indurated plantar fascia sometimes presents fibrous nodules, similar to
those of alcoholic neuritis.'
FlG. iS. — Ankylosing and deforming arthrites, chronic rheumatised type, with atrophy
of the cellular tissue, by nerve irritation, without vascular phenomona, in a case ot
stretching of the two brachial plexuses. (Dejerine, Presse Medical,; 8 July, 191 5.)
The thickened, indurated, contracted, synovial sheaths are attached to
the tendons by adhesions which immobilise them, and, associated with
neuro-muscular contraction, they determine the formation of fibrous claws.
The joint may undergo the same process of sclerosis, sometimes ending
in actual fibrous ankyloses of the digital articulations.
30
NERVE WOUNDS
The phalanges themselves, thickened at their ends, give to the articu-
lations of the fingers a knotty fusiform appearance which in certain cases
may recall the appearance of rheumatoid arthritis, or resemble the " radish
bunch " of gonorrhoea! rheumatism.
Osseous decalcification is a rather common phenomenon, existing in
almost all nerve lesions, but also
found in vascular disturbances
and even after prolonged disuse
of the limb through muscular or
tendon lesions.
Decalcification, however, is
particularly pronounced in certain
nerve irritations.
Lastly, we may meet with
actual atrophy of the paralysed
limb en masse. We have referred
to the conical thinning of the
digital extremities: it is possible
to see, especially in certain cases
of paralysis of the ulnar or of
the posterior tibial, atrophy of
hand or foot en masse : in these
cases, with the muscular atrophy
are associated the thinning of the
skin, sclerous atrophy of the
dermis and osseous decalcification
and deformations of the nails.
In this analytical description
we note how much more fre-
quent and intense in nerve
irritations than in simple nerve sections are all trophic and vaso-motor
disturbances. This is an important point, now well established, and
on which we must insist.
There is only one condition capable of producing trophic disturbances
as marked as neuritic irritation : the arterial obliteration causing ischemic
paralysis. Accordingly this must always be sought systematically, when
we find ourselves confronted with considerable trophic disturbances ; all
the more so as it is frequently associated with nerve lesions, intensifying
and modifying their clinical features.
Fig. 19. — Radiograph of hand (palm facing).
Note the decalcification of the metacarpals
and of the phalanges of the thumb, the
middle finger and especially the index
finger.
VI.— OBJECTIVE EXAMINATION OF SENSIBILITY
Here we are not dealing with spontaneous pains, noticed by the
patient, or with sensations caused by pressure on the muscles or nerve
CLINICAL EXAMINATION OF A NERVE 31
trunks. It is a general questioning of the patient, an objective examina-
tion of muscles or nerve trunks, that supply us with this important know-
ledge.
We are now simply investigating the disturbances of objective, super-
ficial and deep sensibility.
1. Cutaneous sensibilities. — Tactile, painful and thermal sensibility
should be studied in succession.
In reality, this minute examination is not usually necessary, for the
areas of the three sensibilities are usually almost identical. It may at the
same time be stated that thermal anaesthesia is a little more widely diffused
than painful anaesthesia and the latter than tactile anaesthesia.
But here again we are liable to an error of interpretation, for in the
case of each sensibility we must distinguish the coarse sensation from the
fine appreciation of the qualities of the sensation. This is the distinction,
set up by Head, between protopathic and epicritic sensibility ; the vague
sensation of touch is to be distinguished from the clear appreciation of the
nature of the contact and of its precise localisation ; the rudimentary
sensation of pain must be differentiated from the ability to distinguish the,
quality of the pain ; the differentiation between hot and cold must be dis-
tinguished from an exact appreciation of moderate temperatures. These
are so many special sensibilities, corresponding to terminal apparatuses all
the more complex because they supply more precise notions ; in nerve
sections they disappear with a rapidity proportional to their complexity
and become regenerated all the more slowly as they correspond to appa-
ratuses more highly differentiated.
Practically, in the case of peripheral nerves, we may generally dispense
with these minute examinations.
Exploration with a pin alone supplies all necessary information.
By a prick, the pin supplies both tactile and painful sensations ; by the
slight pressure it exercises, however faint, it affords practically adequate
indications regarding deep sensibility.
Speaking generally, it is possible in an anaesthetic area to distinguish
three main zones.
In the first zone, the patient feels nothing ; there is complete superficial
and deep anaesthesia.
In the second zone, the patient perceives the prick of the pin as simple
contact ; he replies : " touch." Probably this sensation is mainly provoked
by pressure of the point; it largely depends on deep sensibility; in this
zone there is superficial anaesthesia with the retention of deep sensibility.
In the third zone, in the neighbourhood of the next nerve region,
a true intermediate zone, the patient vaguely feels the pricking ; he
answers: "pricks a little." There is simple superficial, tactile and
painful hypo-aesthesia ; it is in this zone that slight cutaneous stimuli, with
paint brush, hair, or piece of cotton-wool, begin to be clearly distinguished.
When we reach the intact sensory region of the neighbouring nerve,
32
NERVE WOUNDS
the pricking is keenly felt ; the more so as there sometimes exists slight
marginal hyperesthesia.
20th January (139th day after the wound).
13th March (51st day after suture of the nerve).
Fig. 20. — Examples of different disturbances of sensibility, simultaneous or successive, from
ner-ve lesion. — Extent ot the zones of anaesthesia and hypo-aesthesia to pin-prick, betore
and after nerve suture in a case of complete interruption of the median. In the cross
hatched area, pricking provokes no sensation at all. In horizontal hatched area, pricking
causes only a sensation of contact. In obli(|ue hatched area with crosses : panestheaic
phenomena : hyperesthesia to pain ; diffusion, irradiation, burning sensations, persist-
ence of the sensation. Painful hyperesthesia is specially marked where the crosses are
replaced by dots.
In other cases, we find hyperesthesia either to all modes of sensibility
or to pain only, with hypo-aesthesia to the other sensibilities. This is what
CLINICAL EXAMINATION OF A NERVE 33
may be called painful hypo-esthesia : pin-prick, touch, heat and cold arc
then imperfectly distinguished ; all these stimuli, however, produce the
same painful, badly differentiated and localised sensation, diffused, irradiated
in the neighbourhood and persisting for a few seconds. This painful
hypo-esthesia is the most frequent form of paresthesia encountered in
nerve irritation.
It must not be confused with paresthesia of nerve regeneration. Indeed,
in the restoration of cutaneous sensibilities, we find at an early stage
certain special phenomena, characterised mainly by a sensation of formication
diffused, imperfectly localised, irradiated in the neighbourhood, persistent,
rather disagreeable, provoked by every cutaneous stimulation and particularly
by light stroking.
These cases of paresthesia last long and may persist for several
months.
2. Deep sensibilities. — There must be studied successively :
I. Sensibility to pressure ; the simplest and most practical instrument
is the rounded end of a stylographic pen. Note if pressure is felt in the
region of the nerve. We have seen that the simple pressure of a pin point
suffices to rouse deep sensibility.
II. The sense of attitudes, which consists in finding out if the
patient perceives the movements imparted to his various joints.
III. Bony or periosteal sensibility, which is discovered by means of a
tuning fork placed on the bony projection, and whose vibrations are more
or less distinctly perceived.
The study of deep sensibilities is less important than that of cutaneous
sensibilities. It is subject to more causes of error, its results are less
constant and the role of collateral substitutions is a greater one. The
region of deep anesthesia is always much more extended than that of
cutaneous anesthesia ; and we shall often find, for instance, that pressure
applied at the level of an anesthetic cutaneous region is fairly well
perceived.
The disappearance, likewise, of deep anesthesia is often somewhat
earlier than that of cutaneous anesthesia and may to some extent permit
of our anticipating a speedy restoration.
In every case, after each examination, the exact area of the anesthesia
encountered, whether superficial or deep, must be drawn up, for the
permanence and fixity of the anesthetic region is one of the best signs of
complete interruption. (J. and A. Dejerine and Mouzon.)
On the other hand, the region of anesthesia is found to vary from day
to day in cases of simple nerve compression.
During the regeneration, we see the concentric shrinking of the zones
of anesthesia.
Only by observation and comparison of the successive areas of
3
34 NERVE WOUNDS
sensibility shall we be able to account exactly for the evolution of sensory
disturbances ; this practice is the sine qua non of a complete examination.
VII.— OBJECTIVE EXAMINATION OF THE NERVE
The objective examination of the nerve supplies three important
indications :
1. Whether the nerve is painful on pressure or not.
2. The existence of formication provoked by pressure.
3. The possible discovery of a neuroma.
L Sensibility of the nerve on pressure. — The nerve does not feel pain
on pressure in all cases of section or simple compression.
On the other hand, it is very painful in neuritic or neuralgic irritation
of a nerve trunk; on pressure is is painful along its whole course below
the lesion.
Sometimes the nerve is painful even above the lesion, but this is a
somewhat rare complication.
Pain on pressure must be carefully differentiated from the sensation of
formication also provoked by pressure and having a totally different
significance.
2. Formication provoked by pressure. — When compression or percussion
is lightly applied to the injured nerve trunk, we often find, in the cutaneous
region of the nerve, a creeping sensation usually compared by the patient to
that caused by electricity.
Formication in the nerve is a very important sign, for it indicates the
presence of young axis-cylinders in process of regeneration.
This formication is quite distinct from the pain on pressure, which exists
in nerve irritations.
The pain, indeed, which essentially indicates irritation of the axis-
cylinders and not their regeneration, is almost always local, perceived at
the very spot where the nerve is compressed, or at least magnified at this
spot; it always co-exists with the pain in the muscular bellies under
pressure, very often the muscles are more painful than the nerve.
Formication of regeneration, on the other hand, is but little or not at
all perceived at the spot compressed, but almost entirely in the cutaneous
region of the nerve ; the neighbouring muscles are not painful.
As a rule, it appears only about the fourth or sixth week after the
wound. It enables us to ascertain the existence of this regeneration and
to follow its progress.
If it remains fixed and limited in one spot for several consecutive weeks
or months, this is because the axis-cylinders in their regeneration have
encountered an insurmountable obstacle and are forced to group together
on the spot in a more or less bulky neuroma.
The fixity of formication on a level with the lesion and the complete
absence of formication below the lesion would almost warrant our affirming
CLINICAL EXAMINATION OF A NERVE 35
the complete interruption of the nerve and the impossibility of spontaneous
regeneration.
If, on the other hand, the regenerated axis-cylinders can overcome
the obstacle and make their way into the peripheral segment of the nerve
we sec a progressive migration of the formication so provoked. Pressure
on the nerve below the wound produces this sensation, and from week to
week it may be met with at a spot farther removed from the nerve lesion.
The presence of formication provoked by pressure below the nerve lesion
warrants our affirming that there is more or less complete regeneration.
The zone of formication so brought out changes its place on the
nerve at the same time that the axis-cylinders are advancing; it extends
progressively towards the periphery at the same time that it disappears at
the level of the lesion.
The "formication sign" is thus of supreme importance, since it
enables us to see whether the nerve is interrupted or in course of re-
generation, whether a nerve suture has succeeded or failed, or whether
regeneration is rapid and satisfactory or reduced to a few insignificant
fibres.
Formication lasts a tolerably long time ; appearing about the fourth
week, it persists during the entire regeneration, />., for eight, ten, twelve
months or more, gradually drawing nearer the extremity of the limb. It
ceases only when the regenerated axis-cylinders have almost regained their
adult stage.
Formication, however, may be absent, both on a level with the lesion and
below it ; this absence is an unfavourable prognostic point ; it shows that
nerve regeneration is taking place imperfectly, mainly because of general
disturbances of nutrition.
3. Search for a neuroma along the track of the nerve. — Every nerve
lesion tends to cause the formation of a neuroma at the injured spot. This
is sometimes a simple fusiform thickening of the nerve, sometimes a real
neuroma that is more or less bulky ; at other times, the nerve is simply
embedded in a cicatricial fibrous mass.
By careful palpation we often succeed in recognising the existence of
these neuromatous formations ; besides, the neuroma so compressed is fre-
quently the seat of pain or formication which are provoked, according as
the axis-cylinders which it contains are irritated or regenerating re-
spectively.
Still, too much importance must not be attached to the information
supplied by palpation. First, because there are many causes of error ;
muscular bundles, cicatricial nodules or enlarged glands, may easily be
taken for a neuroma. Again, the discovery of a neuroma affords no
information whatsoever as to the physiological state of the nerve ; there
are neuromata permeable to regenerated axis-cvlinders, and others which
permit the passage of no fibre whatsoever. This is the main point of the
diagnosis, with a view to the prognosis and treatment.
36 NERVE WOUNDS
Consequently, search for the neuroma, involving many causes of error,
never indicates anything more than the seat of the lesion.
As we see, examination of the nerve logically terminates the clinical
examination of the patient. It completes this examination and enables us
to group together and interpret the various symptoms obtained by a study
of the muscles and integuments.
CHAPTER III
ELECTRICAL EXAMINATION
The electrical examination is the indispensable adjunct to the clinical
examination.
To do this with precision often requires the aid of a specialist. Still,
every clinical surgeon, with a little attention, method and practice, may
make it in very simple and tolerably adequate fashion.
The well-established facts of electro-diagnosis have been for several
years largely augmented and illuminated by modern works, especially by
the application to human pathology of the investigation and the methods
of electro-physiology.
For greater clearness we will divide this study into two parts.
1. A setting out of the classic methods of electro-diagnosis.
2. A resume of the recent notions on electro-physiology which complete
them and permit of our interpreting them.
I.— CLASSIC METHODS OF ELECTRO-DIAGNOSIS
Electrical examination essentially comprises two stages :
Examination by the faradic current ;
Examination by the galvanic current.
1. Examination by the faradic current may be done in two ways :
1. By the unipolar method, involving the application, on the nape
of the neck or on the lumbar region, of a large indifferent electrode and
the excitation of nerve and muscles by the small active electrode (negative
by preference). It should be applied to the motor point of the muscle
which generally corresponds with the point of entrance into the muscle or
the nerve twig which supplies it.
2. By the bipolar method, in which we apply the two electrodes to
the nerve or muscle to be examined, so as to include the motor point
when separated by a few centimetres.
As a rule, the bipolar method is but little used in faradic examination
of the muscles. In our opinion, however, it is simpler for making a rapid
examination of the muscular groups ; it is the method illustrated by the
works of Duchenne of Boulogne.
38 NERVE WOUNDS
On the other hand, examination of the nerve is more difficult by this
method, the result being that the unipolar method is almost always
preferred.
In any case, a successive examination of nerve and muscles should be
made, always employing a vibration of from one to three shocks per second.
Use will mostly be made of a thick wire coil, the resistance of which
is no more than one to two ohms.
Examination of the nerve must be made carefully, as this is far more
painful than examination of the muscles.
If possible, it should be done above and below the nerve lesion, note
being taken of the jerks produced in the corresponding muscles.
Indeed, it may happen that the excitation of the nerve above the
lesion causes no movement at all, whereas we note below the lesion a
relative retention of excitability. In this case there are two possibilities :
sometimes it is a recent lesion where the peripheral part of the nerve,
separated from the central portion, has not had time to degenerate com-
pletely ; or else, in certain cases of simple compression of a nerve trunk,
the lesion is sufficient to arrest the transmission of nerve excitation, 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-
bility : this is the phenomenon described by Erb in musculo-spiral
paralysis by compression.
When excitation of the nerve above the lesion provokes contractions
in the muscles supplied by it, we may naturally state that it is not inter-
rupted, at any rate in all its fibres.
Faradic exploration of the muscles with the thick wire coil enables
us to ascertain the entire series of disturbances, from simple hypo-
excitability to complete faradic inexcitability.
i. Simple hypo-excitability is judged by comparison with the same
muscle on the healthy side. It is necessary to sheathe the coil more
deeply to obtain equal muscular contraction. This will be more easily
recognised by seeking on each side for the excitation capable of causing
very small contractions ; this is the faradic threshold, which is measured
according to the length of coil sheathed. It is unnecessary to remark that
this method of measurement is very uncertain, even altogether incorrect,
for the electric units produced by the coil are not at all proportional to
the lengths of sheathing. It would be better to substitute for notation
of the length of sheathing, notation in the quantity of electricitv induced,
a measure which is quite a relative one, and which some makers now
inscribe on their coils.
2. Faradic inexcitability always accompanies complete peripheral
paralysis. There is only one exception to this rule : the paradoxical
phenomenon just mentioned in the slight and fleeting compressions of a
nerve trunk.
ELECTRICAL EXAMINATION 39
Apart from this particular case, ;i rather rare one, all nerve interrup-
tion or prolonged compression is accompanied by faradic inexcitability.
This is one of the essential features of the reaction of degeneration.*
If we use a sufficiently strong current, we often observe the contrac-
tion of the neighbouring and antagonistic muscles, produced by diffusion
of the current. This is what is called antagonistic contraction. It has
no other significance than to demonstrate by comparison the marked
hypo-excitability or the complete inexcitability of the muscle involved.
Faradic inexcitability appears at an early stage; it is one of the first
signs of the RD and persists for the entire duration of the paralysis.
Faradic contractility reappears only very late, after the return of the first
voluntary movements, as Duchenne of Boulogne has demonstrated. But,
we must also remember, this law is only true if we use a wire coil of
feeble resistance.
Examination of nerve and muscles by the faradic current is very
important for the clinical surgeon, inasmuch as when complete faradic
inexcitability is established, one is almost sure to find with the
galvanic current a reaction of degeneration that is typical or at all events
partial.
On the other hand, faradic examination enables us readily to dis-
tinguish organic peripheral paralysis from functional paralysis in which
faradic contractility is always maintained.
There are but two exceptions, already mentioned, to this rule. On
the one hand, very recent paralysis in which the RD has not yet come
about ; then we find faradic excitability rapidly disappearing. On the
other hand, the slight nerve compressions, presenting the paradox of Erb,
in which the nerve and muscles are excitable below the lesion, whereas
the nerve is inexcitable above ; in a few days or weeks we find the
voluntary movements reappearing.
Apart from these two cases, all paralysis characterised by maintenance
of a nearly normal faradic contractility is not peripheral paralysis. It
is functional paralysis, hysterical or simulated ; or else of central origin,
from cerebral lesion or injury of the tracts in the spinal cord, and always
accompanied by manifest objective symptoms, disturbances of the reflexes,
Babinski's sign, etc.
* It is important to note that we are here speaking only of relative faradic inexcitability,
which is determined with the ordinary instruments and the thick wire coil. Indeed, we Bball see
that this fact is only true if we modify the usual conditions of examination. Even if there exists
complete faradic inexcitability with the thick coil, faradic inexcitability of the muscle is ap-
parent only ; 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
muscles examined to undergo electrotonic mollifications by the simultaneous passage of a galvanic-
current. Whenever, then, we speak of faradic inexcitability, we mean this relative excitability, foi
the thick wire coil.
40 NERVE WOUNDS
Faradic examination also gives us other information of less import-
ance : the faradic sensibility of skin and muscles. This sensibility seems
to be the first to reappear during nerve regeneration.
In all this description, we have considered only the usual faradic
examination, with the thick wire coil. To this method alone apply the
classic ideas as to faradic excitability of the muscles.
On the other hand, if a coil of greater electro-motive force is used, a
fine wire coil, for instance, the resistance of which may reach 800,
1200 ohms or more, we find important modifications.
Indeed, in certain cases, we may ascertain the persistence of a slight
faradic contractility in spite of a very pronounced partial RD or even a
complete RD ; a rather strong excitation produces slight muscular
contractions, sometimes very short, oftener slow, like those produced by
the galvanic current on the degenerated muscle.
We may also see the return of faradic excitability as one of the first
signs of nerve regeneration, when the RD is still complete, as shown by
P. Marie, Meige and Mme. Benisty. Consequently, investigation of
faradic excitability with a fine wire coil might with propriety supply the
place of investigation of galvanic reactions of regeneration, and one might
follow the whole progression of faradic excitability up to the normal.
Later on we shall see how these apparently paradoxical results may be
interpreted.
In any case, this process of examination is not to be recommended.
It requires currents of relatively great intensity and consequently
painful ; the contractions obtained in the degenerated muscles depend
not only on the intensity of the current, but also on the duration of the
exciting wave, which is extremely variable ; it depends on the charac-
teristics of the coil, on the phenomena of self-induction, on the produc-
tion of rupture sparks, which increase the duration of the passage of the
current, etc.
This method, then, gives inconstant results and inaccurate information,
it cannot be measured and so is greatly inferior to galvanic examination.
On the other hand, Babinski, Delherm, and Jarkovski have shown that
it is possible to cause faradic contraction to reappear in paralysed muscles
by associating with faradization the passage of a galvanic current into the
limb. This latent faradic excitability seems to constitute an intermediate
degree between hypo-excitability and utter inexcitability.
2. Examination by the galvanic current. — This examination may
also take place by the unipolar or the bipolar method ; but here the unipolar
method is far preferable : one might almost say that it is practically the only
one possible.
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44 NERVE WOUNDS
The examination is made with a large dorsal indifferent electrode and
a small electrode applied to the motor points; this electrode is made positive
or negative in turn by means of a current reverser (Courtade's key).
The nerve and the muscles supplied by it will be examined in turn.
It must be remembered that muscular contraction takes place only at
the moment of the closing and of the opening of the current. The closing
contraction, the stronger one, is generally the only one sought for. The
contraction on opening the current, requiring greater intensity, is seen only
in certain pathological states.
Three elements of muscular contraction under the galvanic current
require special study.
i. The intensity of the current necessary to produce at the closing the
minimum contraction ; this is the threshold of excitation.
In an injured nerve, it will be possible to ascertain the diminution or
disappearance of galvanic excitability. Galvanic inexcitability is the
absolute rule in all cases of interruption of the nerve.
In the paralysed muscle, on the other hand, galvanic inexcitability is
a very rare phenomenon ; • it is found only in cases where the degenerated
muscle has finally lost all contractile structure and has become transformed
into a mere bundle of connective tissue. This is the last stage, long
delayed, of muscular degeneration.
Almost always we find in the paralysed muscle an apparent simple
hypo-excitability. It can be measured by the number of milli-amperes
necessary to obtain contraction, rising from one or two (the normal figure)
to five, ten, or twenty-five milli-amperes.
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.
On the other hand, it varies considerably according to the point of
excitation of the muscle ; from one, two, three milli-amperes by excitation
of the motor point the figure easily rises to four, five, eight milli-amperes
as soon as one moves from this point. Consequently, minute search must
be made for the motor points of each muscle.
2. The pole capable of inducing, with the same current, the strongest
contraction ; or rather, the pole susceptible of inducing the minimum
contraction with the weakest current.
We must therefore compare the negative threshold and the positive
threshold.
Normally it is the negative pole which, on the closing of the current,
induces the strongest contraction ; this is expressed in the following
formula : —
KCC > ACC.
If contraction is stronger at the positive pole, we have an inversion of
the polar formula, and this is written —
ACC > KCC.
ELECTRICAL EXAMINATION 45
If the contractions arc equal, there is said to be polar equality.
Certain muscles, particularly the supinator longus, the tibialis amicus,
the peroneals, sometimes exhibit normally the phenomenon of inversion or
of polar equality.
3. The form of contraction.
Normal contraction is rapid and short, a sudden flash.
In peripheral paralysis with degeneration, contraction becomes slow
and delayed.
Frequently when compelled to use a current of considerable intensity,
it is diffused over the neighbouring or antagonistic muscles. Then there
is observed an initial short contraction of the antagonists, followed by
slow contraction of the muscles involved. Sometimes it is difficult to
distinguish this slow contraction from simple return of the stimulated
antagonistic muscles to the normal state.
ELECTRICAL SYNDROMES
1. Syndrome of nerve interruption. — Reaction of complete degene-
ration. — In cases of peripheral paralysis both the faradic and the galvanic
examination almost invariably give concordant results, the sum total of
which constitutes the reaction of degeneration.
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. As we shall see, this apparent galvanic hypo-excitability
is due to inexcitability of the nerve twig involved at the motor point ; the
muscle itself is really hyper-excitable, especially at the beginning of
the RD.
Of these three latter elements, it is slow contraction that seems to be
of greatest importance. Without great hypo-excitability and without
polar inversion, slow contraction seems sufficient to characterise the RD.
We must add to these characteristics what is somewhat erroneously
called the displacement of the motor point ; this latter appears no longer to
have its seat at the upper part of the muscle but to be approaching its lower
insertion, being found at times even in the neighbourhood of its termination
on the tendon. In reality, 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. This is Doumer-Huet's longitudinal reaction,
characterised by the fact that the muscle is more excitable at the level of the
muscular body and especially in the neighbourhood of the tendon. This
longitudinal excitation almost always occurs along the negative pole, even
when there is complete RD, and polar inversion at the motor point.
The slowness of contraction to longitudinal excitation is often more
46 NERVE WOUNDS
marked than to excitation at the motor point. It often persists even when
excitation at the motor point of the muscle, in process of recovery, begins
to give a quick contraction.
The longitudinal excitability of the paralysed muscle is greater than that
of the healthy muscle. This is one of the facts that demonstrate the
hyper-excitability of the paralysed muscle ; its hypo-excitability is but
apparent, resulting from the inexcitability of the motor twig supplying it ;
but the muscle itself, deprived of its nerve, is really more excitable than
in the normal condition. This galvanic hyper-excitability of the muscle
is often very marked during the first few weeks of paralysis.
It is also by longitudinal excitation that we most easily find the opening
contraction : always stronger at the positive pole, in contradistinction to
the closing contraction, it is easy to provoke only in cases of complete RD,
with hyper-excitability of the paralysed muscle.
The reaction of complete degeneration is generally related to complete
interruption of the nerve.
It does not come about all at once, but within a fortnight or three
weeks ; it gradually becomes more pronounced, passing through all the
phases ; by degrees the nerve loses all excitability ; the muscle loses its
faradic excitability with the thick wire coil and then with the thin wire coil,
at the same time that galvanic hyper-excitability, polar inversion, slow
contraction and longitudinal reaction become obvious.
Nerve regenerations, after complete interruption, act in exactly the
opposite way. On examining the muscles, we find that galvanic hypo-
excitability diminishes, that polar inversion becomes polar equality and then
returns to its normal form ; slow contraction gradually accelerates ; we
ascertain the reappearance of faradic sensibility and faradic contraction
with the thin wire coil, then faradic contractility with the thick wire
coil reappears, though generally tardily and preceded by the return of
voluntary contractility.
The nerve also slowly resumes its normal excitability. As a rule the
voluntary movements appear before the excitability of the nerve.
As the different muscles of the same nerve region resume their functions
according as they are affected by the progression of the regenerated axis-
cylinders, we note the first signs of improvement in those muscles supplied
by the nerve nearest the origin of the limb. There result therefrom
dissociations in the reaction of degeneration.
In a paralysed muscle we may also note the return of the normal
reactions in some muscular fibres at the upper part of the muscle, around
the motor point, whereas the lower fibres still present the RD and still
respond to longitudinal reaction by slow contraction.
2. Syndromes of compression or irritation. — Reaction of partial
degeneration. — The RD is usually incomplete or only faintly indicated
ELECTRICAL EXAMINATION 47
if there is no nerve interruption, in simple compressions or in cases of
moderate nerve irritation.
Very different types of partial RD may be found.
Sometimes it consists of a simple widespread hypo-excitability of nerves
and muscles to the faradic and galvanic currents.
At other times it consists of a faradic and galvanic hypo-excitability of
the muscles, along with inexcitability of the nerve trunks. It is in these
cases that we can at times observe the slowness of the contraction under
the faradic current.
In other cases, there is lacking only one factor to the complete RD :
the contraction is not very slow, or else, whilst slow to the positive, it is
quick to the negative, corresponding to the slightest forms of the RD ;
again it is the polar inversion that fails, or rather it disappears when we
cross the threshold of excitation ; or again we find that longitudinal hyper-
excitability fails.
3. Syndromes of fibrous transformation. — Electrical inexcitabimty
of the muscle. — In the complete RD, we have seen that galvanic excit-
ability was retained; apparently diminished if we seek excitation at the
motor point, but in reality increased if we excite the muscular body itself
or seek longitudinal reaction.
This excitability of the muscle may be seen to diminish or even
disappear completely, at all events with currents of twenty-five to thirty
milli-amperes, the only ones that can practically be utilised in electro-
diagnosis.
This reaction of muscular hypo-excitability or inexcitability always
indicates very profound lesions of the muscle ; it shows that the muscle
has lost its contractile structure, and that it has undergone more or less a
process of infiltration or one of fibrous transformation. This reaction
is met with in certain cases of long-standing nerve interruption ; it
appears more quickly in muscles left untreated by either massage or
electricity.
Consequently it has a relatively serious prognosis. It should, how-
ever, be known that this muscle, even after fibrous transformation, may
slowly regain its normal characteristics if the regenerated axis-cylinders
reach it soon enough;
The syndrome of muscular hypo-excitability or of muscular inexcita-
bility is found with quite special frequency in nerve irritation, which so
often causes fibrous contraction and infiltration of the muscles.
It is often superposed on the RD, emphasising, sometimes to an
enormous degree, the galvanic hypo-excitability of the muscles.
In other cases, it exists without the RD, it is then characterised by
marked hvpo-excitability of the nerves and muscles to the faradic and
galvanic currents. It is found in these cases that, in contradistinction to the
syndrome of the paralytic partial RD, the hypo-excitability of the muscle
48 NERVE WOUNDS
to the faradic and to the galvanic currents at the motor point is not
accompanied by the usual longitudinal hyper-excitability.
In certain cases, one may even ascertain the apparently paradoxical
association of the following symptoms :
The nerves and muscles are almost incapable of being excited by the
usual faradic and galvanic currents ; but violent faradic shocks, or galvanic
currents at the motor point up to twenty-five or thirty milli-amperes produce
rather feeble contractions of small areas, limited to a few muscular fibres ;
we are surprised to find that these contractions are quick, without polar
inversion.
As Huet has shown, this reaction after all has a relatively favourable
prognosis. It shows that the muscle has undergone a more or less pro-
found fibrous transformation, from lack of attention or else from nerve
irritation ; but at the same time it indicates the persistence of healthy, or
the arrival of some regenerated axis-cylinders and enables us to predict the
slow restoration of motor functions.
4. Reaction of Exhaustion. — Sometimes we find in weakened muscles,
and oftener during muscular regeneration, an indication of the reaction
of exhaustion described by Jolly in myasthenia.
The muscle makes unequal responses to successive faradic excitations,
or rather, if we utilise a somewhat rapid faradic rhythm, we find a con-
traction fail from time to time ; there are "misses" comparable to those
of cardiac arhythmia in myocardial lesions.
In other cases, if the muscle is excited by a rapid rhythm or a
tetanising current, it is found to become rapidly inexcitable.
5. Myotonic Reaction — Lastly, in some cases of slight neuritis,
usually accompanied with contraction, the muscles seem to be slightly
hyper-excitable under the faradic current ; tetanisation seems to take place
with interruptions somewhat less rapid than in the normal state, which
simply shows, after all, a certain prolongation of the contraction. This,
however, is not the true myotonic reaction, which is mainly characterised
by a tonic, lasting contraction, persisting after the cessation of galvanic
excitation. It essentially characterises Thomsen's disease and certain
myopathies. It does not exist so clearly in cases of nerve lesion ; all the
same, in recent cases of paralysis one may at times observe a faint con-
traction persisting during the passage of the galvanic current. This is
the exaggerated manifestation of galvano-tonus, or galvanic hyper-excita-
bility of the muscle, which exists in recent RD.
*****
The disturbances of electrical reactions and the RD in particular
essentially characterise peripheral paralysis, i.e. those which result —
From lesion of the motor cells of the spinal cord (poliomyelitis,
hematomyelia, etc.) ;
ELECTRICAL EXAMINATION 49
From lesion of the anterior roots (inflammation of the roots, com-
pressions, etc.) ;
From traumatic lesion of the plexuses or peripheral nerves ; from the
polyneurites.
Functional, hysterical paralyses and paralyses of cerebral origin or
resulting from lesion of the pyramidal tract (upper motor neurone) are
never accompanied by important disturbances of the electrical reactions.
At most there is slight hypo-excitability from muscular disuse.
At the same time, in sections of the cord, we may frequently note im-
portant electrical disturbances, as remarked by P. Marie and Foix, but they
manifestly result from the reaction of the grave medullary lesion on the
motor cells of the anterior horns below the lesion.
Only one affection is accompanied by electrical disturbances as profound
and rapid as those of the peripheral nerve lesions, this is ischemic paralysis
from arterial obliteration. Still, we see rather the syndrome of fibrous trans-
formation of the muscles than the true RD ; inexcitability of the muscles
comes on earlier and is more marked than the inexcitability of the nerve
controlling it.
II.— SOME POINTS IN ELECTROPHYSIOLOQY
Modern investigations in electrophysiology now enable us to complete
and interpret the information supplied by the classical electro-diagnosis.
Three important points stand out prominently :
1. The active pole — which is always the negative pole, at the closing
of the current ;
2. The galvanic hyper-excitability of the muscle deprived of its nerve ;
3. The velocity of excitability or chronaxie.
1. Polar Action. — It now seems proved that the negative pole alone
is capable of producing a closing contraction with the galvanic current.
Consequently, the contraction obtained by the positive pole in the
paralysed muscles and characteristic of polar inversion of the RD, is falsely
attributed to the action of this pole. It results from the action of a virtual,
negative pole, appearing deep within the tissues and in the muscle itself.
1. As a demonstration, an interesting experiment made by Cardot and
Laugier may be given.*
A frog's gastrocnemius and the nerve supplying it are placed in a small box made
of paraffin wax, divided into two compartments by a partition traversed by the nerve.
Thus there are two separate rooms, the one for the muscle, the other tor the nerve, which
passes across the partition and penetrates the muscle.
A wide indifferent electrode supports the muscle, a small active one surrounds the
nerve.
* H. Cardot and A. Laugier. Journal Je Physiologic ct Je Pathologic generate. Paris, 1912.
4
5 o NERVE WOUNDS
Each of these electrodes may be made positive or negative at will ; whenever the
current is established, and in whatsoever direction, the muscle contracts.
We have to discover which is the active pole, and upon what it acts, nerve or muscle.
Now, Lapicque has shown that the velocity of excitability or ckronaxie of a neuro-
muscular system varies with the temperature. Thus, by varying the temperature of one
of the two compartments, the variations of chronaxle can be studied and the problem
solved.
Indeed, if the nerve compartment and the nerve itself are brought into different
temperatures, with the negative pole we shall obtain corresponding differences of velocity ;
if, on the other hand, we apply to the nerve the positive electrode, the velocity of
excitability remains invariable, whatever the variations of temperature.
Conversely, if the temperature of the compartment containing the muscle is made lo
vary whilst maintaining the nerve at a constant temperature, we find that only excitation
of the muscle by the negative pole is affected by the variations of temperature.
Thus it is demonstrated that the negative pole alone is active at the
closing of the current for nerve and muscle alike, since the negative
excitation alone is influenced by variations of temperature.
It has also been shown that, at the opening of the current, the positive
pole alone is efficacious. But the opening contraction at the positive pole
is usually not utilisable in electro-diagnosis. It requires an intensity eight
to ten times greater than the closing contraction at the negative pole.
2. This principle that the negative pole alone is active at the closing
of the current thus seems in formal contradiction to the results of the
electro-diagnosis in the paralysed muscles, showing the existence of a polar
inversion and of a closing contraction at the positive pole.
An experiment of Bourguignon * clearly shows that this contradiction
is but apparent.
Thus, if we apply a small active electrode to a superficial nerve,
close to muscular bellies independent of its motor supply (as, e.g., is the
musculo-spiral nerve, in the groove of the biceps or the median at the
inner surface of the arm), we obtain by a rather powerful negative or
positive excitation very different results.
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.
The closing excitation at the same point by the positive pole, however,
causes no movement in the muscles supplied by the nerve. On the other
hand, we notice a contraction in the neighbouring muscles, biceps and
triceps.
Positive excitation, then, has not taken place in the nerve placed in
contact with the electrode ; it has, however, affected a distance the muscles
next to this nerve.
It is therefore proved that the positive pole in contact with the nerve
is inactive. The motor response, a distance, of the neighbouring muscles
* Bourguignon. Revue neuro/ogique, April 30, 19 14.
ELECTRICAL EXAMINATION 51
is due to the existence of a virtual negative pole, which the real positive
pole, applied to their surface, causes to appear in the neighbouring
muscles.
This virtual pole, however, appearing deep in the tissues, along the
course of the lines of force, naturally has not the density of the superficial
pole represented by the small active electrode. Its action, consequently,
is diffused ; it falls upon the mass of the muscles and not in a precise-
energetic fashion on the motor nerve twig innervating them.
From these facts, the following conclusions may be drawn : —
The negative pole, at the closing of the current, exercises a direct,
precise and limited action on the nerves and muscles with which it is in
contact. Moreover, it causes to appear deep in the tissues a virtual
positive pole, inactive and devoid of importance.
The positive pole, on the surface, acts indirectly at the closing, through
the virtual negative pole which it causes to appear deep in the tissues.
This excitation, therefore, is more diffused, indefinite and imperfectly
limited ; having less density, it requires a far greater intensity to produce
the same results.
These facts enable us to explain the electrical reactions of a normal
muscle and of a paralysed muscle.
(a) If we excite a healthy muscle at the motor point, we rind that it
contracts at the closing of the current, under the direct action of the
negative pole, with a very small current ; for instance, the threshold is at
one to two milli-amperes. The excitation has acted directly, with great
intensity, on the motor twig of the muscle. In these conditions it "has
produced the maximum of useful effect.
At the same point, with the same current, the positive pole is altogether
ineffective. The intensity of the current must be sensibly increased to
find the positive threshold, i.e. to cause to appear in the muscle a virtual
negative pole, capable of producing, in spite of its diffusion, an equally
strong excitation.
If the muscle is excited outside of the motor point, at the level of the
muscular belly, or by longitudinal excitation, we at once see that greater
intensity is needed to obtain the threshold of contraction. For instance,
five, six, eight milli-amperes are needed to obtain the contraction. This
is because excitation no longer acts directly on the motor twig but is
diffused with less intensity in the muscle itself.
Again, we shall see that the muscle responds almost as well and often
even far better to the positive pole. In this case it is excited by the
virtual negative pole in its depth.
Thus we understand why we may find in a healthy muscle false polar
equalities and false polar inversions, when the excitation does not bear
exactly on the motor point, or when the real motor point is with difficulty
accessible on the surface.
52 NERVE WOUNDS
{l>) In a paralysed muscle there is no longer any real motor point ; the
nerve twig supplying it is inexcitable.
On the other hand, the muscle itself has retained its excitability ; we
shall even see shortly that this excitability is usually increased. It contracts,
however, only under the influence of a diffused current, distributed
throughout the muscular belly, the density of which current, consequently,
will be less great, whilst, in order to produce the same contraction as the
excitation of the nerve, it will have to possess greater intensity.
In these conditions, the muscle makes a similar response when excited
at the motor point or at a distance from this point ; by excitation of the
muscular belly itself and especially by its longitudinal excitation we obtain
even a stronger contraction than at the motor point : this is the
phenomenon inaccurately designated as the descent of the motor point, or
more correctly the longitudinal reaction.
If the negative electrode is applied to the muscle in its lower part or
in the neighbourhood of the tendon, the current directly excites the
muscular fibres throughout their whole length ; longitudinal reaction is
thus almost always produced more readily by the negative pole.
If, on the other hand, the negative electrode is applied to the upper
part of the muscle, near the motor point, the muscular fibres are excited
only partially and feebly ; if we use the positive electrode, it causes to appear
in the muscular body a virtual negative pole, the action of which on the
muscular fibres is direct and far more effective than surface excitation ; we
obtain polar inversion.
2. Hyper-excitability of the paralysed muscles. — Galvano-tonus.- —
Apparently the paralysed muscle is less excitable under the galvanic
current than the healthy muscle. The contrary, however, is the case.
The paralysed muscle has lost its nerve excitability, i.e. it is impossible
to excite at the motor point the nerve twig which normally responded to
a very feeble current.
The muscle itself, however, has retained its excitability, which is more
difficult to provoke than that of the nerve, on account of the diffusion ;
consequently it requires greater intensity.
This electrical excitability of the paralysed muscle is frequently intensified,
just as we have found its mechanical excitability intensified, as shown by
the idio-muscular reflexes.
Only after some time, with the progress of muscular atrophy, the
prolonged disuse of the muscle and the gradual disappearance of the
contractile structure, do its electrical and mechanical excitability diminish
and finally disappear.
There are two ways of accounting for this hyper-excitability of the
recently paralysed muscle.
First, by investigating the threshold in the neighbourhood of the
motor point ; the muscle usually responds to the positive pole.
ELECTRICAL EXAMINATION 53
Polar inversion takes place and we find that the positive threshold is
often less raised on the paralysed muscle than on the healthy one.
Secondly, we can more easily recognise this hyper-excitability by
longitudinal excitation. The muscle almost always responds to the
negative pole, and this threshold of longitudinal excitation is always far
less raised than on the healthy muscle.
In some cases there is also seen to appear the opening contraction
which is difficult to obtain on the healthy muscle with bearable currents.
This hyper-excitability of the paralysed muscle, shown by longitudinal
excitation, is particularly clear in cases of recent paralysis ; it diminishes
with the progress of the atrophy. It may even appear in muscles in-
completely paralysed and thus demonstrate very slight nerve lesions. It
disappears somewhat rapidly as soon as nerve regeneration manifests itself.
It is sometimes called galvano-tonus.
A therapeutic effect results from this conception of the longitudinal
hyper-excitability of the paralysed muscle.
It is logical to provoke by longitudinal excitation the contractions used
in galvanic treatment ; they are fuller, more complete and easier to obtain
with feeble currents ; the method of longitudinal excitation produces the
maximum of effect with the minimum of current.
3. Velocity of excitability. — Chronaxie. — The conception of velocity
of excitability, introduced into electrophysiology by Engelmann, Dubois,
Weiss, Lapicque, etc., has only of recent years found a practical applica-
tion in electro-diagnosis.
It is, however, most important, as are also its practical consequences.
I. 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 minimum intensity (for an indefinite duration of
passage).
In order that a muscle may contract, there must be excitation of the
muscle or nerve supplying it with a minimum of intensity ; this is the
threshold of excitation.
That this minimum current, however, may be effective, it must last
some time ; below this minimum duration the same current remains
ineffectual ; if this duration is increased, the muscular contraction obtained
at the opening remains the same, however long the current takes to pass.
If we diminish the minimum duration of the passage of the current,
there is no longer any contraction by the liminal current ; contraction
can be obtained only by increasing the intensity of the current.
This minimum duration of the liminal current, capable of determining
the threshold of excitation indefinitely, is a measure of the velocity of
excitabilitv.
For practical reasons, most recent researches have utilised another
54 NERVE WOUNDS
measure of velocity of excitability. First, the physiologists determine
the threshold of excitation for a current of indefinite duration : this is the
rheobase or rheobasic threshold of Lapicque. Then we seek the velocity
of excitability for a current twice as intense as the rheobase. To this
minimum duration of passage for a double intensity of the rheobase
Lapicque gave the name of chronaxie.
The minimum duration of passage for the liminal current, and
chronaxie, are two different measures of the velocity of excitability ; the
former is about ten times greater than the latter.
The relation between duration and intensity of the liminal current is
particularly important. For the same muscle of the same species in
identical conditions it is invariable.
Consequently it supplies a mathematical and measurable basis for
reckoning the excitability of a nerve or muscle.
It is also an extremely sensible method ; the works of Lapicque and
his pupils have demonstrated the considerable variations of chronaxie
according to the temperature and the different physiological and patho-
logical states of nerves and muscles; the slightest and most fleeting
injuries of the nerve twigs are shown by considerable modifications of
chronaxie ; the traction of a nerve trunk, its slight compression, the action
of cocaine, ether, chloroform, etc. ; are immediately revealed by variations
of the velocity of excitability, corresponding to fleeting modifications of
the structure of the nerve. ( Lapicque and Legendre. )
In spite of its importance, however, the fact of chronaxie has long
enough eluded the researches of observers, for the durations of passage
to be studied are extremely short. We may see this when we reflect
that chronaxie of the frog's gastrocnemius muscle, for instance, at a
temperature of 15 , is about three ten-thousandths of a second.
In man, 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, on the other hand, easily reaches forty, fifty,
sixty thousandths of a second ; thus it is excitable only by a relatively pro-
longed current : its chronaxie is slow. The difference is seen to be great ;
nevertheless the results, even approximate, given by the different methods
of research, are of considerable value.
*****
The application of these facts to electro-diagnosis has hitherto en-
countered many difficulties, mainly resulting from the resistance of the
skin and from the extreme variability of muscular excitability applied
through the integuments.
Three processes have been advanced for reckoning the velocity of
excitability : First, two indirect processes, that of Cluzet by discharges of
condensers ; that of Bourguignon and Laugier by comparison of faradic
excitability at the opening and closing of the induced current ; second, a
ELECTRICAL EXAMINATION 55
direct process, recommended by Lapicque, the simplification of the
methods utilised in electrophysiology for measuring the duration of a very
short galvanic current.
(a) Discharges of Condensers (Cluzet).* — Condensers of different
capacity, but of the same voltage, discharge themselves according to a
duration proportional to their capacity.
According to their capacity they may supply currents of variable
duration.
It will be sufficient first to produce the voltage corresponding to the
threshhold of contraction for an indefinite current (rheobasic voltage).
Then, if the condensers are charged at the same voltage, or rather at double
the rheobasic voltage, we have only to find out the feeblest of the con-
densers capable of producing contraction. The measure of capacity of
this condenser gives the duration of the discharge, consequently the velocity
of excitability.
Practically, this method, of which we have simply set forth the barest
schematic data, involves a certain number of difficulties arising mainly
from cutaneous resistance which varies according to the intensity of the
current and even, in the case of a current of constant intensity, according
to the duration of this current. We shall find these same difficulties in
all the methods proposed.
The results obtained, therefore, constitute only approximations ; never-
theless they are sufficiently precise to reveal the slightest lesions and enable
them to be expressed in figures, the value of which, relative though it be,
is nevertheless great.
(/;) The Process of Bourguignon and Laugier. — Relation between
the Induced Waves of Opening and Closing. — It is well known that
in an induction coil, when the primary current (inductor) is closed, there
is induced in the secondary a current in the opposite direction ; on the
opening of the primary current there arises in the secondary a current of
the same direction as the inductor current.
These two induced waves, of closing and opening, have not the same
characteristics. Their direction is inverse, but this is of no great import-
ance. On the other hand, they are unequal in duration and intensity ;
this gives them a different physiological action.
In the induced waves of closing and opening, naturally, the quantity
of induced electricity is equal. The closing wave, however, is long, con-
sequently its intensity is less ; the wave of opening is short, and its intensity
is greater.
This difference results from the way in which the current is set up ;
the closing current of the primary started in the induction coil is set up
* Cluzet. Lyon Medical, 26 November, 191 I ; Journal dt Radiologic ft a"E/cctro/ogie t
March 1914.
56 NERVE WOUNDS
slowly, because of self-induction. The primary closing current and the
resulting induced current are consequently prolonged and slowed down.
On the other hand, at the opening of the primary, no resistance of
self-induction takes place, the wave resulting therefrom, both in the
primary and in the induced, is short, almost instantaneous even, if care
has been taken to extinguish the rupture spark which tends slightly to
lengthen the opening wave.
In the induction coils usually employed in faradic excitation, only the
opening wave, short and intense, is efficacious. The shortness of this wave
explains why it is capable of exciting only the normal muscle, with rapid
chronaxie. It is ineffective in the paralysed muscle, with slow chronaxie,
unless its voltage is enormously increased by using an induction coil of
adequate electro-motive force and considerable sheathing. This explains
the contractions sometimes obtained in paralysed muscles by thin wire
coils (usually of 800 ohms). With a coil of 1600, 1800, and even 3000
ohms, we can almost always obtain contraction of a paralysed muscle, but
the intensity is very great and the excitation painful.
On the other hand, the opening wave is long, consequently it is capable
both of exciting normal muscles with rapid chronaxie and degenerated
muscles with slow chronaxie.
Thus, with the same coil, an adequately powerful one, we have two
waves of unequal though constant duration, a short wave and a long one.
Let us first produce the threshold of excitation with the short opening
wave, and note, by the sheathing of the coil, the intensity necessary for
contraction. A healthy muscle, with rapid chronaxie, contracts with the
short wave as soon as it reaches the rheobasic threshold with extremely
small sheathing. A paralysed muscle, with slow chronaxie, will contract
with the short wave only if it attains a far greater intensity, much superior
to the rheobasic threshold with considerably greater sheathing.
Afterwards let us produce the threshold of excitation with the long
closing wave. The healthy muscle will again contract when the rheobasic
threshold has been reached ; given the less intensity of the closing wave
by reason of its longer duration, there will be needed a greater sheathing
of coil than for the opening wave, usually almost double. The paralysed
muscle, with slow chronaxie, will also be contracted by the long wave,
when the threshold of excitation has been reached ; i.e., with an intensity
somewhat higher than that of the healthy muscle and a scarcely greater
sheathing.
In a word, for the healthy muscle, between the sheathing, conse-
quently between the intensity of the opening and closing thresholds, there
is a considerable divergence, explained by the smaller efficacy of the
closing wave ; in the case of the paralysed muscle the difference is consider-
ably diminished, because owing to its slow chronaxie the paralysed muscle
ELECTRICAL EXAMINATION 57
requires, along with the short opening wave, a comparatively far greater
intensity.
If we reduce to quantities (micro-coulombs, measured by the ballistic
galvanometer), the value of the currents employed, we are able to establish
a real indication, almost constant for one and the same coil, of the excita-
bility of healthy muscles.
The lowering of the index gives the diminution of the constant of
excitability of the muscle.
Below we offer an example, taken from Laugier.
Case of musculo-spiral paralysis from compression. Examination of the
extensor carpi ulnaris.
OPENING (SHORT WAVE).
Distance of coils. Quantities.
Heathy side . . . 14*375 cm. or 27*5 mi-
cro-coulombs.
Paralysed side. . 10*75 cm « or 9^ micro-
coulombs.
CLOSING (LONG WAVE).
Distance of coils. Quantities.
7 - 75 cm. or 288 micro-coulombs.
6 cm. or 431 micro-coulombs.
The index of excitability determined by the relation between the opening and
closing amounts is respectively : —
TT , . . . 288 micro-coulombs , r . . ., . ,
Healthy side , or 10*5 normal figure tor the coil employed.
27-5
Paralysed side — , or 4-4.
As we see, this indirect method of reckoning the velocity of excitability
may give tolerably accurate results. It enables us to follow mathematically
the entire evolution of a paralysed muscle.
Two things may, however, be brought against it.
First, it supplies only relative figures ; the constant varies according to
the coil employed ; the constants of each coil must be determined and an
examination made always with the same instrument.
Then, too, it is rather complicated ; the main difficulty arises from the
fact that at the intensities at which the closing contraction manifests itself,
the opening contraction is violent and practically unbearable. It is con-
sequently necessary to eliminate it carefully either by working the inter-
ruptor by hand or by utilising Bourguignon's special interrupter enabling
one to eliminate at will the opening contraction.
(<:) Lapicque's Chronaximetre. — Lapicque recently issued the model of
a simplified chronaximetre* for clinical use.
This is a "rotatory mechanical rheotome, to which movement is communicated by ;i
suitable heavy weight falling from a moderate height and carrying a light shaft by
* L. Lapicque. Academe des Sciences, Comptes rendus, t. clxi, p. 643, seance du 22 Novembre,
1915.
58 NERVE WOUNDS
a wire placed over a pulley with decreasing radius ; a pointer fixed perpendicularly on
this shaft describes a circle at a velocity increasing as the square of the time : in this
way, I have obtained at the end of the first turn, which alone can be used, an angle of
7° to 8° per thousandth of a second. Two specially made interrupters, worked in
succession by the passage of the pointer, give clearly and securely (as experience has
shown) current durations that can be regulated from a fraction of a thousandth of a
second up to a tenth of a second.' 1
It suffices first to determine the threshold of excitation to closing of
the negative, for a current of indefinite duration. This is the well-known
negative threshold of electro-diagnosis ; the rheobase of the physiologists.
Then we must, with the same current though of definite duration
measured by the chronaximetre, try to find the minimum time necessary
for obtaining contraction. This duration supplies directly the velocity of
excitability.
We must remember that physiologists prefer to take as their starting
point a double intensity of the rheobase.
That we may avoid too short durations, it is preferable in clinical
electro-diagnosis to seek chronaxie, starting with the rheobase itself.
Perhaps the results are somewhat less precise, but the durations are
longer and easier to reckon.
The variations in chronaxie revealed by this method between the healthy
muscle and the paralysed muscle are enormous. Whereas a healthy muscle
contracts at one to two thousandths of a second, and often far below one
thousandth, chronaxie of a paralysed muscle, manifesting the RD, easily
rises to forty, sixty thousandths of a second, and even more.
This difference is less easy to estimate than the delay and slowness of
galvanic contraction, which, after all, are but the objective expression of the
same phenomenon.
Without claiming the precision of an apparatus in physics, the
chronaximetre enables us to estimate chronaxie of a muscle with tolerable
rapidity ; to reckon its degree of excitability and to follow by successive
measurements its entire pathological evolution.
Nevertheless, it must be confessed that these researches, even simplified,
are always too prolonged ; several hours are often necessary for the
methodical examination of the muscles of a single patient.
Muscles, too, in a state of prolonged inactivity, show a sensible diminu-
tion in their velocity of excitability. 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.
4. Selective excitation of paralysed muscles. — A second important
application of the idea of chronaxie has been proposed by Lapicque.
In electro-diagnosis we are considerably impeded by contraction of the
antagonistic muscles excited by diffusion. We may eliminate this contrac-
tion of the antagonistic muscles which have remained normal and limit
excitation to the paralysed muscles alone by utilising a progressive current.
ELECTRICAL EXAMINATION 59
In 1907-1908 Lapicque showed that if a current increases gradually to
a constant intensity, the diminution of efficacy resulting from this retarda-
tion is smaller in proportion as chronaxia is slower.
When we are at the threshold of excitation, or even a little above, if
the galvanic current gradually attains its constant intensity, in six or eight
thousandths of a second, for instance, the normal muscles and nerves, with
small short chronax'ie, undergo no excitation whatsoever. The degenerated
muscles, with slow chronaxie^ on the other hand, are excited by a progressive
current, even if this current reaches its intensity only in fifty or one
hundred thousandths of a second.
We need then only introduce the current by degrees in order to limit
contraction to the paralysed muscles alone.
Lapicque produced this retardation by using condensers, placed in
series. A condenser of two microfarads causes the current to take about
six thousandths of a second to reach 95% of its constant intensity. By
progressively introducing greater capacities, up to ten, twenty, thirtv
microfarads, if the hypo-excitability of the paralysed muscle necessitates
the use of a more intense current, we finally suppress altogether the con-
traction of the healthy muscles, without in any way modifying the efficacy
of the current in the paralysed muscle.
The same observation is of considerable importance in electrotherapy.
Indeed, it is necessary to limit to the paralysed muscles, as far as possible,
the contractions provoked by the current.
By utilising currents progressively, we shall do away with the contrac-
tions produced in the healthy muscles, and, without any pain, can utilise
greater intensities.
This is obtained progressively with special interrupters, with metallic
vibrators, or with immersion vibrators (Bergonie, Bordier, etc.) the use of
which has recently been highly recommended.
CHAPTER IV
CLINICAL TYPES
The most important and difficult problem to solve in peripheral paralysis
is that of the nature of the lesion. This diagnosis requires surgical inter-
vention or abstention ; it enables us to form a prognosis as to the future of
the paralysis.
The minute study of the many cases of peripheral paralysis, undertaken
since the outbreak of war in the various neurological centres, enables us to
differentiate a certain number of clinical syndromes relating to various nerve
lesions and involving diametrically opposed therapeutic solutions.
Along with J. and A. Dejerine and Mouzon we may describe four
syndromes that are fundamental, typical and clearly characterised :
Syndrome of interruption ;
Syndrome of compression ;
Syndrome of irritation ;
Syndrome of regeneration.
To these must be added dissociated syndromes resulting from partial
lesions of the nerve, and also complex syndromes produced by association in
the same nerve of two or more of the preceding syndromes, in connection
with the different or unequal lesions of the various fasciculi of which it is
composed.
We may also add the syndrome of ascending neuritis, which is rather a
complication than a consequence of nerve lesions.
In reality, however, the clinical manifestations of nerve lesions are even
more varied and numerous than this enumeration suggests. A study
of nerve wounds enables us continually to group new categories and
distinguish new symptomatic forms. Irritation of the nerve trunks, in
particular, direct or even ascending, is indicated in many different clinical
pictures, sometimes by simple neuralgia, sometimes by violent pains, of a
character special to the causalgia of Weir Mitchell ; sometimes by trophic
disturbances which especially characterise neuritic forms, and sometimes
even by states of muscular hypertonia which come under the heading of
contracture.
Consequently, we shall have to dwell at some length on the manifesta-
tions of nerve irritation and the polymorphous symptoms it may call forth.
CLINICAL TYPES 61
1.— SYNDROME 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 is complete interruption of the nerve fibres ;
their peripheral 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, such lesions are capable of spontaneous
regeneration. This will come about by a progressive growth of the axis-
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 is frequently insurmountable to
the regenerating fibres ; the segments of the sectioned nerve are not in
contact, compression is too great, the cicatricial mass is formed of too
dense fibrous tissue. In all these cases, the regenerating fibres springing
from the central end will be unable to join the peripheral empty sheaths
which serve them as conductors, they will group themselves at the level
of the obstacle, forming a neuroma, or else will stray about in the
neighbouring cicatricial tissue.
Thus, complete interruptions often call for surgical intervention :
either decompression in certain cases, or, more frequently, nerve suture
after resection of the injured segment. 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 of interruption is characterised —
i. By immediate, complete, absolute and invariable paralysis of the
muscles supplied by the interrupted nerve.
2. By a progressive and particularly rapid disappearance of muscular
tone, culminating in complete muscular hypotonia. It precedes atrophy,
which occurs more slowly.
3. By well-marked progressive and regular muscular atrophy.
In spite of hypotonia and atrophy, the idio-muscular reflexes are
intensified, for a very long time at least, 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
two or three weeks and culminates in the complete classical RD.
From the outset the nerve excited above the lesion no longer transmits
any excitation to the muscles 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 in a few days their faradic contractility (with
the thick wire coil), then, much later, after a month or even more, their
faradic excitability with the thin wire coil (the usual coils).
At the same time we have the disappearance of the motor point,
polar inversion and longitudinal hypo-excitability. Galvanic contraction
becomes slow, its appearance is retarded and its execution slackened.
5. By immediate, complete and invariable anaesthesia in the region
supplied by the paralysed nerve.
Anaesthesia is a little more widely spread the first few days ; its area
gradually diminishes for some weeks owing to anastomotic substitutions ;
then it remains definite and fixed. Ac-
cording to the case, it is somewhat variable
in its characters ; in principle, it is abso-
lute, involving all the superficial and deep
sensibilities, though this is true only for
large areas of anaesthesia.
Deep anaesthesia, indeed, is always, by
reason of anastomotic substitutions, much
less widely extended than superficial
anaesthesia ; it is, on the other hand,
evoked by very slight cutaneous pressure :
when the patient is pricked with a needle,
and he feels simply the contact not the
prick, this is because deep sensibility is
involved. In the exploration process
with the pin which we have recommended,
the answer " touch " applies mainly to
deep sensibility.
In these conditions, when the anaes-
thetised region is not very extensive, deep anaesthesia is never complete ;
the pressure of the pin is everywhere felt, the feeling of pain alone is
abolished, and we have simple hypo-aesthesia.
6. By the absence of spontaneous, or induced pains by pressure
on the nerve and the muscular bellies. Not only are the muscles not
painful, but, as Dejerine has remarked, they are quite insensitive to
pressure.
The nerve lesion itself is alone somewhat painful.
7. By the absence of formications caused by pressure on the nerve
below the lesion.
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.
1 2
Fig. 21. — Example of fixed anaes-
thesia in complete interruptions.
Section of the sciatic in middle
part of thigh. 1. Examination
on the 1 6th June, 191 5, six weeks
after the wound. 2. Examination
on the 9th October, 1 9 1 5.
CLINICAL TYPES 63
It must be remembered that formication appears as a rule only about
the fourth or sixth week, and that it disappears in the end.
8. By the absence of trophic disturbances, except occasionally slight
oedema, a little cyanosis and moderate hypertrichosis.
Serious trophic disturbances, cutaneous sclerosis, aponeurotic contrac-
tions, 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 ulcers, which are always secondai v
to a cutaneous injury ; these are, for instance, plantar ulcers produced
by walking, sores on the great toes or the dorsal surface of the foot
occasioned by the 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 all, these are always accidental ulcers, favoured and pro-
longed by malnutrition of the tissues in the region of the interrupted
nerve.
From this schematic description we conclude that —
() 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 destruc-
tion of the axis-cylinder or centrifugal degeneration.
In a word, we have here a local disorganisation which momentarily
causes to disappear the physiological conductivity of the nerve fibre; but
this fibre is not dead ; its peripheral segment is not degenerated ; it is
capable, after the disappearance of the injury, of being reorganised and
64 NERVE WOUNDS
resuming its functions fairly rapidly. This is the syndrome produced in
the momentary compressions of a nerve ; its classical example is musculo-
spiral paralysis, called " a frigore," produced by compression of the nerve
during deep sleep.
Sometimes this syndrome is found in the permanent compression of a
nerve surrounded by a fibrous cicatrix or encased in callus, but without
marked narrowing.
In these cases, however, permanent compression, compatible for a
considerable time with anatomical survival of the nerve, may finally
induce its progressive degeneration ; consequently, we may find a syndrome
of compression being transformed into one of interruption.
On the other hand, the same injury may induce destruction of a certain
number of more fragile nerve fibres and simple compression of the rest.
This results in a mixed and very usual syndrome, one of incomplete inter-
ruption, where the symptoms of interruption are never fully seen, and
where, nevertheless, we observe progressive regeneration, far slower than
simple restoration of a compressed nerve.
The syndromes of momentary compression must be compared with
the fleeting paralyses which often succeed grave injuries of the limbs, and
which have been described as a kind of stupor of the nerves : these
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 of compression is characterised —
1. By more or less complete paralysis, generally as complete as in the
syndrome of interruption, more rarely partial and permitting of a few ill-
defined movements.
2. By muscular atrophy, far more rapid and less intense than in
complete interruption.
This atrophy may, however, become very intense, if compression
persists.
3. By relative preservation of muscular tone which is one of the best
signs of simple compression.
Still, one may also find muscular tone disappearing after a time ; this
muscular atony, however, requires months, whereas it takes only a few
weeks in complete interruption.
The idio-muscular reflexes are almost always intensified ; if they are
normal it shows that the compression is very slight.
4. By a reaction of partial and always incomplete degeneration, far
slower in taking place ; unless we have progressive interruption oi the
compressed fibres.
It is in slight compressions, particularly in musculo-spiral paralysis from
temporary compression, that we may find the paradoxical electrical
reactions we have already mentioned : nerve and muscles remain more or
CLINICAL TYPES
65
less excitable by the faradic current below the lesion, whilst electrical
stimulation of the nerve above the lesion causes no movement whatsoever
in the paralysed region.
5. By anaesthesia, variable in intensity and extent ; in general it is far
more reduced and less pronounced than the anaesthesia of interruption ; in
any case it has no invariable fixity.
6. By the absence of pains at the level of the lesion, as also of pains
in the course of the nerve or on pressure of the muscular bellies ; these
latter, however, may retain their normal sensibility to pressure.
7. By the absence of formication. This is altogether absent in simple
and transitory compressions, as is musculo-spiral paralysis a frigore. If
we find, in some cases of close and prolonged compression, slight
Fig. 22. — Attitude of the hand in a case of simple compression of the musculo-spiral
nerve. The paralysis 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.)
formication of the nerve trunk under pressure, it indicates the destruction
and the consecutive regeneration of some nerve fibres. In a word it is a
case of incomplete interruption.
Whilst regeneration of the few interrupted fibres is taking place, we
find the zone of formication extending over the 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 of trophic disturbances is even clearer in com-
pression than in complete interruption. Usually we do not find in them
the cyanosis and the slight oedema which may accompany the preceding
type.
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 results of liberation are somewhat variable. In simple
compressions we often find that the nerve regains in a few weeks,
sometimes a few days, the whole of its functions.
In compression with incomplete interruption, the duration of restora-
tion is evidently proportional to the nerve destruction.
The fibres momentarily or slightly compressed present only segmentary
lesions, i.e., limited to the affected point, 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 more deeply affected, the peripheral segment is injured
secondarily, and the 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.
In almost every case of compression calling for surgical intervention,
simple liberation of the nerve is usually sufficient. Resection and suture
are called for only in cases where prolonged constriction has transformed
the nerve into a mere fibrous strand ; in these cases, the syndrome of
compression had given place to that of complete interruption.
III.— SYNDROMES OF IRRITATION
Irritation of a nerve trunk may show itself by extremely varied and
diversely associated symptoms.
We will describe schematically :
i. Serious nerve irritation ;
2. Slight nerve irritation ;
3. Irritation of a simple neuralgic form ;
4. A special neuralgic syndrome accompanied by violent pains and paroxysms ;
the causalgia of Weir Mitchell.
The phenomena of nerve irritation or neuralgia in a mixed nerve may be
associated with paralysis, though they may also exist without total paralysis.
It may even be stated that paralysis is 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.
CLINICAL TYPES 67
I.— SYNDROME OF SERIOUS NERVE IRRITATION
This syndrome is found only in lesions of the mixed nerves which alone
possess numerous vaso-motor and trophic fibres whose irritation produces
neuritic disturbances.
It is almost always accompanied by paralysis ; this paralysis, however, is
frequently less complete than in the preceding forms, for the nerve fibres
are irritated, not destroyed. For instance, there persists a suggestion of
voluntary movements or else a certain degree of electrical excitability.
The RD is frequently partial.
Muscular atrophy isextremely variable. Whilst, for the most part, it is less
marked by reason of the relative preservation of the nerve fibres, in other
cases we find extremely rapid muscular dissolution.
Muscular tone is usually preserved, sometimes even intensified by
fibrous infiltration of the muscles.
The idio-muscular reflexes are always intensified, although the fibrous
transformation of the muscles may frequently mask them.
Trophic and painful sensory disturbances are the essential characteristics
of neuritic types.
Whereas, however, motor disturbances occur immediately, pains and
trophic disturbances are secondary.
After a few days the pain appears and it gradually becomes more
pronounced for two or three weeks, to continue for months and then
slowly disappear.
It is also after a few weeks that trophic disturbances appear, persistence
of which often brings about definite lesions.
A. — Sensory Disturbances
Pains. — The main symptom is pain.
Spontaneous pains comparable to sensations of burning, pricking )
muscular rending.
Pains intensified by movement and muscular contraction, by heat and
more especially by cold, by cutaneous friction or by contact of the bed-
clothes.
Pains occasioned mainly by pressure on nerve trunks and muscular
bellies ; these pains are felt at the compressed point; they also extend over
the whole limb. Generally they are more acute on pressure of the
muscles than of the nerve trunks.
Cutaneous hyperesthesia. — The skin also is painful. In certain cases,
it is true, we may note the presence of cutaneous anesthesia, which, however,
is found along with the pain on pressure of the deeper tissue. More
68 NERVE WOUNDS
frequently, however, there is painful hyperesthesia, which usually coexists
with a tactile and thermal hypo-aesthesia.
Indeed, touch, friction, cold and heat are but vaguely perceived ; even
pricking is ill defined ; but all these cutaneous stimuli produce one and
the same painful sensation, imperfectly localised and differentiated, diffuse,
radiated, continuing several seconds and altogether characteristic.
B. — Trophic Disturbances
Trophic disturbances belong strictly to the syndrome of nerve irritation.
In these cases we note the presence of cedema, cyanosis and hyper-
trichosis, already found in nerve interruption.
More especially do we find the whole series of severe trophic dis-
turbances —
Extreme dryness of the skin, its fibrous infiltration and its desquamation
in broad scales, or, on the other hand, the appearance of profuse fetid sweats,
or again the condition known as glossy skin.
Nails curved, furrowed, split, cracked, claw-like.
Conical atrophy of the digital extremities.
Fibrous infiltration and contraction of the muscular bellies ; contraction
of the tendons and aponeuroses, which lead to the formation of irreducible
griffes.
Immobilisation of the tendons by fibrous invasion of the synovial sheaths.
Fibrous ankyloses of digital or carpal joints and of deformed joints
reminiscent of rheumatoid arthritis.
A more rapid and pronounced bony decalcification than in any other
type.
*****
Pronounced neuritic types are therefore essentially serious, mainly by
reason of their trophic disturbances.
Indeed, whilst the paralyses that accompany them are always destined
to heal spontaneously or by liberation of the nerve, the pains that characterise
them, however acute they may be, must inevitably diminish and disappear ;
on the other hand, the fibrous and mucular contractions, the tendon
immobilisations, the griffes, the articular scleroses, too often constitute
refractory lesions which necessitate months or even years of painful
mobilisation and of massage, and sometimes remain altogether irreducible.
Most of these severe neuritic types heal spontaneously, with the
exception of the fibrous sequelae of the healing process.
Spontaneous regression is indicated by the mitigation of pain and by
the appearance of formication.
During the entire period of irritation, the nerve is painful, though
there is no formication when pressure is applied. As soon as neuritis
calms down, we note the appearance of formication at the level of the
CLINICAL TYPES 69
lesion ; then, week by week, it is seen to descend along the tract of the
nerve which, with the neighbouring muscles, ceases to be painful ; formi-
cation then gradually replaces in the nerve the neuritic pain, driving it
forward, as it were. Speaking generally, the slowness of the regeneration
in neuritic types is discouraging.
In obstinate cases, liberation of the nerve seems to give variable results ;
sometimes it brings about a great and rapid improvement ; frequently it is
ineffective. Probably the inconstant nature of the results is due to the
character of the lesion ; irritation may be external to the nerve, or, on the
other hand, may take place within it.
In certain particularly intense forms, where serious and definite trophic
disturbances are to be feared, it is right to practise resection of the lesion
and suture of the nerve. By this means, the pains are immediately dis-
pelled, the evolution of trophic disturbances is suppressed and it is possible
to practise massage, mobilisation and electrical treatment, all of which had
been impossible before by reason of the intensity of the pains.
II.— ATTENUATED NEURITIC TYPE
We have described the grave forms of nerve irritation, but we must
remember that its manifestations may be far more widely disseminated.
A little pain on pressure of the muscular bellies, a slight fibrous infil-
tration of the muscles, a few aponeurotic or tendon contractions, 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.
Frequently slight neuritic disturbances may be dissociated. For
instance, we may find pain on pressure of the muscles, with fibrous con-
traction but without pronounced cutaneous trophic disturbances ; this is
the origin of some cases of pes equinus, from slight lesion of the sciatic.
Muscular atrophy may be absent, we have even seen cases where slight
irritation of the sciatic nerve was shown by actual hypertrophy of the
muscles of the calf, accompanied by slight contraction and fibrous infiltra-
tion of the muscles, more bulky and resisting than on the healthy side.
Moreover we shall see later what relations can be established between
these disturbances and contractions from neuritis.
In these cases of neuritis affecting the muscular system we occasionally
find neither hyperesthesia nor even cutaneous hypoaesthesia ; whilst, on
the other hand, the muscles are painful when pressed. The pain is deep,
not on the surface.
In other cases aponeurotic contractions prevail, resulting in the forma-
tion of fibrous grijfcs ; sometimes nerve irritation is rather ill-defined and
aponeurotic sclerosis so tardy that the nerve lesion may pass unnoticed.
7 o NERVE WOUNDS
For instance, we have seen cases of contraction of the palmar fascia,
reminding one of Dupuytren's contracture, occurring slowly after a
wound in the arm or the fore-arm and apparently inexplicable ; the most
minute investigation has been needed to discover, not only a certain
degree of pain on pressing the nerve, but even slight formication along its
course and hypo-aesthesia of its cutaneous area, thus proving slight irritation
of the ulnar.
Sometimes again cutaneous trophic disturbances preponderate. In
certain slight neurites of the musculo-spiral, for instance, attention is
first attracted by the fibrous infiltration of the skin on the dorsal surface of
the fingers, its adhesion to the first joints and the limitation resulting
therefrom in flexion of the fingers.
Still, speaking generally, the exclusively cutaneous manifestation of
trophic disturbances is more apt to accompany the neuralgic type which
we will now investigate.
III.— SIMPLE NEURALGIC TYPE
Following on slight bruises of the nerve trunks, we often meet with
more or less pronounced neuralgic syndromes.
No trophic disturbances occur, at most a few signs of cutaneous irrita-
tion. There is no paralysis, but only a certain degree of weakness and
muscular atrophy, without appreciable modification of the electrical
reactions.
Instead of anaesthesia, there is slight hyper-aesthesia to pin-prick in
the area of distribution of the nerve.
The patient complains solely of more or less acute pains radiating
along the course of the nerve, provoked mainly by the movements involving
the lengthening of the limb, such as the extension at elbow, neck and
knee in the case of the median and the sciatic, which are most frequently
involved.
The muscular bellies are somewhat sensitive to pressure. The nerve
trunks, however, are more so ; and this pain is manifested above all at the
points of election. On the sciatic are found all the Valleix points and
Lasegne's sign ; indeed, we are dealing with real injuries to the sciatic.
These traumatic neuralgias are often rather persistent, they may con-
continue for several months and then disappear spontaneously.
Naturally their intensity is very variable, and every type may be found.
They are syndromes of slight irritation, of a well-marked sensory type.
They are specially to be distinguished from the violent neuralgic
syndromes of a particular character, for which must be reserved the name
of " causalgia."
CLINICAL TYPES 71
IV.— INTENSE NEURALGIC TYPE— CAUSALGIA
In 1864, after the War of Secession, S. Weir Mitchell descrihed under
the name of causalgia a particular neuralgic syndrome, characterised hy its
intensity, its long duration, its special pains and its habitual resistance to
every therapeutic agency.
All the nerves may be attacked by causalgia, but it is particularly the
median and the sciatic that produce this syndrome, doubtless by reason
of the number, importance, and perhaps fragility or special .nature, of their
sensory or vaso-motor fibres.
Very seldom does causalgia appear immediately after the wound ;
almost always the. pains supervene only after four or five days; they
take three or four weeks to reach their maximum, and then continue for
months, finally calming down very slowly.
Causalgia is essentially characterised by violent pains, compared by
patients to a sensation of mingled smarting and burning (kq,v, Maximum flexion of the fingers.
c, d, e,J\ Voluntary and electrical contractility of the muscles.
gi h, Cutaneous sensibility to pin-pricking.
i, Osseous sensibility /, Articular sensibility
to tuning-fork. to passive attitudes.
1 1
1 62 NERVE WOUNDS
Fig. 137. — Case of Corporal Chev ... 30 April, 1915, 71st day after his wound.
Compression of external surface of left ulnar nerve in the upper arm (partial lesion).
Corporal Chev ... of the 228th Infantry, wounded on the 18th Feb., 1915, at
Suzanne (Somme), by the bursting of a shell. The projectile traversed the inner region
of the left arm, four fingers 1 breadths below the armpit. Suppuration of tract and
drainage. Ulnar paralysis seems to have been immediate, but for several weeks move-
ment of the arm was rendered almost impossible by reason of the pains set up in the
last two fingers, doubtless connected with the pulling on the nerve. These pains had
almost disappeared at the time the wounded man entered the hospital.
Operation, 17 May (88th day after the wound), by M. Gosset. Ulnar nerve bent
on a very hard fibrous cord which strongly compressed its external surface, and was
stretched between the external edge of the biceps and the outer bend of the biceps. Re-
section of this cord. The nerve was normal in calibre, aspect and colour, with the
exception of a slight swelling and hardening (interstitial sclerosis) of its external part.
a, Attitude of the hand at rest (disturbances of tone).
Note : 1. That the hand, in its entirety, is deviated towards the radial edge (atony of
flexor carpi ulnaris).
2. That there is no trace of "ulnar griffe." On the other hand, 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 is greater than that of the corresponding slips of the flexor
profundus).
3. That atrophy of the adductors of the thumb, at the thenar eminence, seems more
pronounced than atrophy of the hypothenar eminence.
4. That abduction of the little finger (as regards the axis of the hand) is very
marked ; this abduction seems connected, on the one hand, with the favourable tone of
the muscles of the hypothenar eminence, and, on the other hand, with the tonic action of
the extensor tendons, whose role as abductors is intensified when the hand, as in this
case, finds itself deviated towards the radial border.
5. The considerable hyperkeratosis that exists throughout the entire paresthetic
region of the ulnar nerve, and which extends right to the region of the median.
b, c, Maximum flexion of fingers.
Note : 1. That projection of the flexor carpi ulnaris above the pisiform is quite
absent.
2. That there is no flexion of the last phalanx in the case of the last two fingers,
and only imperfect flexion in the case of the middle finger.
3. That flexion of the first phalanx of the fingers is effected better than in the case
of Fig. 1 01, and also better in the latter fingers than in the former (the outer interossei
are more weakened than the inner interossei).
e >f>g> Muscular contraction in voluntary movements and movements of resistance,
and by electrical stimulation.
Black : no appreciable voluntary contraction ; doubtful contraction to electrical
stimulation of the nerve above the lesion 5 partial RD.
Hatching : voluntary contraction is possible, though diminished. These muscles
contract to electrical stimulation of the nerve above the lesion (diadermic stimulation) ;
partial RD. (The hatching is closer, because voluntary contraction is less.)
Dotted: slight weakening ; electrical hypo-excitability, without RD.
h, Articular sensibility to passive positions : no disturbance whatsoever, i. Osseous
sensibility to tuning fork, j, k, Cutaneous sensibility to pin-prick.
In oblique hatching : painful hypo-a;sthesia to pin-prick ; slight bony hypo-xsthesia.
In oblique cross-hatching : paresthesia.
In oblique dotted-hatching: very painful paresthesia.
Dotted: painful hyperesthesia, strictly so-called (no enlargement of Weber's circles)
osseous hyperesthesia.
A comparison of Figs. 101 and 102 shows that, deep in the ulnar nerve on the arm,
the general arrangement of the fasciculi seems to be as follows : from within outwards,
the cutaneous sensory (dorsal and palmar) branches along with the branches to the
hypothenar eminence — then the deep branch of the nerve, the branches of the last
interosseous spaces being within, those of the last spaces further without, those of the
adductors of the thumb still further- and lastly, on the outer surface of the nerve the
fasciculi for the flexor carpi ulnaris, and for the flexor profundus (inner slips).
a. Attitude of the hand at rest.
b, c, Maximum movements of flexion of fingers.
l ^ e ->J,K, Voluntary and electrical contraction of muscles.
h, Articular sensibility i, Osseous sensibility
to passive attitudes. to tuning-fork.
/', i\ Cutaneous sensibility to pin-prick.
164
NERVE WOUNDS
DIAGNOSIS OF ULNAR PARALYSIS
Diagnosis of ulnar paralysis requires little more than the indication
of a few causes of error.
Fig. 138.
Fig. 139. — False ulnar griff e by cicatricial contraction of the flexors of the last two
fingers. Relax the contracted muscles, flexing the fingers on the hand or the hand on
the wrist, to obtain reduction of griff e.
ULNAR NERVE 165
1. Note the frequent absence of the typical ulnar griffe, which may be
scarcely perceptible.
Nothing is easier than to be mistaken regarding paralysis of the ulnar,
and perhaps more particularly as regards complete paralysis through lesion
of the nerve above the epitrochlea ; indeed, it is in this case that griffe
is least pronounced, owing to paralysis of the flexor profundus.
It should be remembered that almost all movements of the ulnar may
be reproduced by substitutionary movements. True, these are far weaker,
but a superficial observation might lead us to imagine that we were dealing
with simple paresis of the nerve. Lateral adduction alone of the fifth
finger cannot be substituted ; this is almost the only movement which is
absent in certain cases.
2. Just as we may be mistaken in ulnar paralysis so may we regard as
an ulnar griffe the simple cicatricial contraction of the flexors of the last
two fingers.
In this case, indeed, there is a real resisting griffe, apparently inexten-
sible, and therefore reminding one of the fibrous griffe in nerve irritation.
It is felt, however, when employing traction in order to straighten the
griffe, that the resistance is in the fore-arm, not in the hand ; the traction
movements raise like cords the contracted muscles and draw on the scar.
Finally, if care is taken to flex the fingers on the metacarpus, or the
hand on the fore-arm, free play is given to the contracted muscles and it
is noticed that the griffe is completely reduced, without deformity of the
fingers.
It is unnecessary to add that the hypothenar eminence and the inter-
ossei show no sign of atrophy.
3. Finally, we must insist on certain contractions appearing in the
ulnar distribution. They often give rise to appearances which might be
mistaken for ulnar griffes and paralyses.
CONTRACTIONS RESULTING FROM SLIGHT NEURITIS OF
THE ULNAR
Contractions of the hand constitute a very special, important and
interesting chapter in the study of irritations of the ulnar.
Indeed, there are often found, following slight wounds of this nerve,
states of muscular hypertonia or even of real contraction, to which we
have already called attention.
Whilst all slightly irritated motor nerves seem susceptible of producing
analogous syndromes, the ulnar would appear to produce them with special
frequency. As the median seems to respond very frequently to slight
irritations of its sensory fibres, producing the causalgic syndrome, so the
ulnar seems to manifest greater susceptibility of its motor fibres and to
react readily to their irritation, producing the hypertonic syndrome. It is
1 66 NERVE WOUNDS
generally a case of direct lesion of the nerve, sometimes indirect compres-
sion or lengthening by traction ; in other cases, the nerve seems irritated
by a process of slight ascending neuritis.
We note in every case the appearance of muscular hypertonia,
frequently amounting to contraction, and immobilising the hand in a
fixed attitude.
All the muscles have retained their normal electrical reactions, but
they are contracted. Active movements are impossible, passive move-
ments are difficult and meet with considerable resistance of an elastic type
which is non-fibrous and almost always painful. As a rule, the pain dis-
appears as soon as contraction is overcome and the movement carried out ;
left to itself, however, the hand, either immediately or more slowly, in a
few minutes or in a few hours, regains its original condition.
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 ; pain in the nerve under pressure, formication caused by
percussion, anaesthesia or hypo-assthesia of the cutaneous area, vaso-motor,
sweat or trophic disturbances, mechanical and often electrical hyper-
excitability of the contracted muscles, all these clearly demonstrate the
irritative origin of these hypertonic syndromes.
Nothing could be more variable than the contracted attitudes produced
by irritation of the ulnar ; indeed, the different muscles supplied by this
nerve have antagonistic functions, and according as any particular group
is preponderant we find altogether different attitudes. Nor must it be
forgotten that contraction becomes fixed and intensified by immobilisation.
Contraction in flexion, for instance, becomes contraction in extension, if
after overcoming it we immobilise it in this attitude. We may con-
sequently see in one and the same patient different attitudes succeeding
one another. The main types we will now review.
Sometimes we have contraction of the muscles of the hand, producing
the " accoucheur's hand " type described by Froment and Babinski. The
fingers are pressed against one another or even intercrossed by contraction
of the palmar interossei ; the thumb is immobilised by the adductors, the
little finger is kept in a state of forced adduction.
As a rule, contraction does not affect the thumb and is even at
times confined to the hypothenar eminence ; the little finger is in forced
adduction and obliquely crosses the anterior surface of the other fingers.
In all cases, there is immobilisation of the fingers in extension by the
action of the interossei on the second and third phalanges.
Wc also find that certain cases in which it is impossible to flex the
fingers, particularly the last two fingers, are due to contraction of
the interossei.
Immobilised when extended, these fingers do not offer to passive flexion
ULNAR NERVE 167
the fibrous and articular resistance which we find in certain cases of
Fig. 140. — Contraction limited to the hypothenal eminence with slight contraction of
the palmar interossei. Ulnar hypo-xsthesia. Hypo-xsthesia of the internal cutaneous.
Pain and formication in the nerve as far as the armpit. Very pronounced trophic
change in the little finger nail. Compression of the ulnar and ot the internal
cutaneous at the level of the armpit, or slight traction on the lower roots ot the brachial
plexus.
Fig. 141. — Contraction with extension ot two fingers; maximum ot voluntary move-
ments. The fingers may very readily be flexed, but they immediately resume their
original attitude as though moved by a spring. Lesion of the ulnar above the
epitrochlea. Ulnar hypo-xsthesia with hypo-xsthesia of the internal cutaneous.
Originally the patient had contraction in flexion of the last two fingers ; after opining
of the hand and immobilisation in extension for several weeks, contraction in
extension occurred.
neuritis. Voluntary flexion of the first phalanx is possible and sometimes
i68
NERVE WOUNDS
even exists permanently, thus showing full movement of the interossei.
Passive flexion of the last two phalanges is possible and even tolerably
easy, affording the impression of elastic resistance, but left to themselves
the fingers at once resume their initial attitude as though moved by a
spring, or else they regain it slowly after a few minutes.
In other cases we find contraction of the hand along with flexion of
the fingers ; of this two typical varieties may be described. Sometimes
we have flexion of all the fingers by the interossei ; flexion then almost
exclusively affects the first phalanx ; the second and third are but
moderately flexed. In these cases there is often more or less pronounced
contraction of the palmar aponeurosis, the existence of which intensifies
l
1
Fig. 142. — Contraction of the hand in flexion. Slight wound of the ulnar in the
middle part of the arm. Liberation of nerve two months after the wound. Con-
traction, which appeared some weeks after the wound, has become exaggerated after
operation. Complete ulnar anaesthesia. Slight hypo-aesthesia of the median. Con-
traction of the palmar aponeurosis. Passive extension of the hand is possible though
painful ; consequently the hand remains extended, voluntary flexion impossible ; in a
few hours it resumes its original flexed attitude.
flexion of the fingers as well as resistance to passive movements ; it clearly
indicates irritation of the nerve trunk.
Soon after we note flexion of the last two fingers on the hand through
contraction of the flexor profundus, producing an attitude which re-
sembles, though somewhat exaggerated, that of ulnar griff e in paralysis
accompanied by neuritis.
Whilst in all these contractions there undoubtedly exists a motor nerve
irritation which causes them, still this is not the main factor, perhaps in
most cases it is not even the most important factor.
As a rule, this irritation acts only by causing a sort of muscular
hypertonia, an actual predisposition to contraction. What more than all
ULNAR NERVE
169
else favours, maintains, and intensifies this ncuritic contraction in almost
every case, is immobilisation. From the time when they are slowly,
patiently, and regularly mobilised, these contractions diminish and finally
disappear.
We are justified in thinking that they would not exist for the most
part if we had practised this daily mobilisation from the outset, and if
the patient had not shown a certain amount of indifference, or even
willingness, in allowing contraction to take place.
This is proved by the habitual preservation of the movements of the
thumb ; even when there is contraction of the interossei, the adductors of
the thumb almost always escape contraction and retain their movements
Fig. 14.3. — Flexion or the last two fingers
may be thought to be due to muscular
fore-arm in its inner part. All the same
complete extension may be obtained w
reproduced several minutes afterwards,
middle part of the arm, hypo-aesthesia of
of the adductors of the thumb, cyanosis
the ulnar part or the hand, point to invol
by a process of ascending neuritis.
by contraction of the flexors. The attitude
contraction, for the wound has affected the
, there is no cicatricial muscular contraction ;
without great resistance, and the attitude is
Pain in the ulnar when pressed on in the
its cutaneous area, simultaneous contraction
of the little finger, profuse sweats noticed in
vement of the ulnar nerve, probably irritated
which the patient finds indispensable in using his hand : out of fifteen
cases of contraction in the region of the ulnar, only twice have we found
immobilisation of the thumb by the contracted adductors.
It must be remembered that these ncuritic contractions are almost
always partially functional ; great care must be taken to prevent their
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.
Once contraction has been established, massage, hot baths, mobilisation
under warm water, the faradic bath with metronome rhythm, have in-
variably given excellent results.
CHAPTER VIII
MEDIAN NERVE
ANATOMY
The median nerve originates in the brachial plexus from two heads :
the outer head, coming from the outer cord along with the musculo-
Lesser int. cut.
Median
Brachial artery
Musculo-spiral
Ext. cut. br.
Musculo-spiral
Ulnar
Biceps
Fig. 144. — Deep nerves of the arm (after Hirschfeld modified).
Anterior aspect.
cutaneous, brings to it fibres of the sixth and seventh cervical roots ; the
MEDIAN NERVE
171
inner head, coming from the inner cord trunk, along with the ulnar,
supplies it with fibres from the eighth cervical and of the first dorsal.
The median nerve descends into the armpit in front of the axillary
artery. It proceeds along the inner side of the arm, lying against the
inner side of the biceps, in front of and outside the brachial artery, which,
Met!.
Musculo-spiral
Post, branch
Sup. long.
Flex, sublim. -
Ext. carpi rati, longior — \Cy
Musculo-spiral (ant. branch)
Pron. quadratus -
Thenar eminence
Pronat. radii teres
Flex, carpi ulnar
Ulnar N.
Flex. prof.
Anterior interosseous
Ulnar (dorsal branch)
Deep branch
Superficial branch
Fig. 145. — Deepinerves of the tore-arm and nerves of the hand (after Hirschteld).
at its lower part, crosses its deep surface and becomes external to it. It
proceeds in front of and outside the ulnar, which is closely united with it
as far as the lower third of the arm.
At this level, the ulnar separates itself from the median to reach the
epitrochlean groove which is behind, whilst the median slightly inclines
172 NERVE WOUNDS
outwards in order to draw nearer to the middle line of the upper limb at
the bend of the elbow.
In the fore-arm, it proceeds between the two heads of the pronator
radii teres, and disappears beneath the superficial flexor. It descends in
the middle line resting on the flexor profundus, covered by the superficial
flexor. Below the fleshy body of this muscle, at the lower part of the
fore-arm, where it becomes superficial, it appears between the tendons of
the flexor indicis and the tendon of the flexor carpi radialis.
It passes on to the wrist under the annular ligament of the carpus ;
occupies the anterior compartment of the radio-carpal canal, and divides
into its terminal branches : the inner trunk and the outer trunk.
Motor Branches
The median nerve does not supply any branch whatsoever to the
arm, except a few twigs for the brachial artery and the articulation of the
elbow.
I. — All the branches of the median in the fore-arm are exclusively
motor, except the palmar cutaneous branch, which appears a little above
the wrist and is destined for the hand.
1. Upper nerve to the pronator radii teres.
2. Nerves to the superficial muscles of the fore-arm, destined :
For the pronator radii teres (lower nerve).
For the flexor carpi radialis and palmaris longus.
For the superficial flexor.
All these branches originate close to the elbow (Cruveilhier) ; but
some accessory twigs also become detached lower down, particularly for
the flexor of the index.
3. Nerves of the deep layer, comprising :
A branch which supplies the two external heads of the flexor profundus ;
A branch destined for the flexor of the thumb ;
A branch which descends, under the name of anterior interosseous
nerve, in front of the interosseous ligament, supplies the pronator quadratus
and reaches the proximate articulations of the carpus, where it ends.
II. — In the hand, the median nerve supplies :
1. The muscles of the thenar eminence by three branches, origi-
nating in its external branch and destined :
For the abductor of the thumb ;
For the opponens ;
For the flexor brevis.
The median does not supply the adductors of the thumb, which the
ulnar supplies in the same way as the interossei.
It also supplies only the superficial part of the flexor brevis ; the deep
head is supplied, partially at least, by the ulnar.
MEDIAN NERVE
173
2. The first two lumbricales, by branches originating in its inner
branch. Occasionally it also supplies the third lumbrical.
Sensory Branches
Whereas in the fore-arm the median nerve is exclusively motor, in the
hand it is mostly sensory.
1. Palmar cutaneous branch. — This collateral branch appears a little
above the wrist and disappears in the skin of the thenar eminence and of
Musculo-spiral N. (ext. br.
Musculo-cutaneous N. ,,
Musculocutaneous N. (ant. br
Musculo-cutaneous N. (post, br.)
Musculo-cutaneous N. (ant. br.)
Anastom. muse. cut. and musc.-spiral
Collat. thumb
- Int. cut. nerve (anter. br.)
_ Int. cut. nerve (anter. branch, ext.
twig)
Inter, cut. nerve, (anter. branch,
inter, twig)
Anastom. cutan. branch and ulnar
Median N. (palm, cutan. branch)
Col. digital
Anterior aspect.
Fig. 146.— Cutaneous nerves of fore-arm and hand. (After Sappey.)
the palm of the hand, which it supplies as far as the middle palmar crease
1 2. The external terminal branch of the median, from which also
originate the motor branches of the thenar eminence, supplies :
The external digital collateral nerve of the thumb ;
The internal digital collateral nerve of the thumb ;
The external digital collateral of the index.
3. The internal terminal branch supplies through the inter-digital
nerves of the second and the third space :
i 7 4 NERVE WOUNDS
The internal digital collateral of the index and the external collateral
of the middle finger ;
The internal collateral of the middle finger and the external collateral
of the ring-finger.
All the digital collaterals of the fingers, except those of the thumb,
successively send out a dorsal branch for the second phalanx and one for
the third phalanx, so that, in the case both of the median and of the ulnar,
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.
Anastomotic Branch
It is useless to enumerate the terminal anastomoses of the median
along with the musculo-spiral, the ulnar, or the musculocutaneous.
Unlike those of other nerves they have no interest for the clinician. This
is not so in the case of the anastomosis supplied to the median by the
musculocutaneous, at the middle of the arm. Probably it supplies the
median nerve with the motor fibres coming from the sixth and seventh
cervical roots ; it is the more developed in proportion as the external root
of the median is slighter ; and so its persistence, in the complete sections
of the median above it, would explain the possible preservation of some
nerve fibres supplying the flexor carpi radialis and the pronator radii teres.
The median also receives in the arm and the fore-arm some slight
anastomotic twigs from the ulnar nerve, capable of supplying occasionally
substitutionary fibres to the flexor profundus of the middle finger.
MEDIAN NERVE
'75
PHYSIOLOGY
147.
Fig.
Motor Syndrome
I. — The median nerve in the fore-arm is exclusively motor.
It controls :
1. Pronation by the pronator quad rat us and the pronator radii teres
Babinski found that, in paralysis of the
median, electrical stimulation of the biceps
produces supination more pronounced than
in the normal state as a result of lack of
antagonism of the pronator radii teres.
2. Flexion of hand on fore-arm by the
flexor carpi radialis, etc.
Nevertheless, in paralysis of the median,
slight flexion of the hand is still possible
by the flexor carpi ulnaris, and the synergic
contraction of the supinator longus and of
the extensor ossis metacarpi pollicis.
3. Flexion of the fingers by the super-
ficial flexor and the flexor profundus. In
spite of paralysis of the median, flexion of
the last two fingers remains possible by
means of slips of the flexor profundus sup-
plied by the ulnar.
The fingers which cannot be flexed in
paralysis of the median are the thumb, the
index and middle finger.
Flexion is absent in the last two
phalanges only ; the ulnar being capable,
through the interossei,
of flexing the first pha-
langes of middle finger
and index on the meta-
carpus.
On the other hand,
in spite of the typical
anatomical descriptions,
the middle finger can
frequently be flexed in
paralysis of the median.
This is not only owing
to the aponeurotic fibres
which unite the flexors
of the middle finger to
those of the ring-finger, but to actual muscular contraction. It must of
Muscles supplied by the median
in the fore-arm.
Fig. 147. — Superficial layer. Pro-
nator radii teres. Flexor carpi
radialis. Palmaris longus.
Superficial flexor.
Fig. 148. — Deep layer. Pronator
quadratus. The two external
fasciculi of the flexor profundus.
Flexor of the thumb.
149. — Superficial layer. Fig. 150. — Deep layer.
Muscles supplied by the median in the hand.
Figs. 149 and 150. — Abductor pollicis. Opponens,
Flexor brevis pollicis. The first two lumbricales.
176
NERVE WOUNDS
necessity be admitted that the flexor profundus of the middle finger is
very often supplied, partially at least, by the ulnar.
II. — In the hand the median nerve supplies all the muscles of the
thenar eminence, except the adductors and the deep head of the flexor
brevis.
Paralysis of the median is mainly characterised by loss of the opposition
and flexion movements of the thumb, whilst adduction persists.
The patient can grasp an object firmly and press it between the
first phalanx of the thumb and the base
of the index, but he cannot pinch it
between the end of the thumb and the last
phalanxes of the index ; still less between the
thumb and the end of the other fingers.
On the other hand, the thumb is capable
of slight external rotation.
Nevertheless, energetic contraction of the
adductors enables it frequently to move to
the ulnar edge of the hand, by crawling,
so to speak, against the base of the fingers.
This is the pseudo-opposition of the thumb
described by H. Claude, facilitated by lack
of tone in the other thenar muscles and by
articular laxity.
The flexion movements of the thumb
are completely suppressed (long and short
Fig. 151.— Pseudo-opposition in flexors) ; still, a slight flexion movement of
paralysis of the median. The , 111 • ■ n -i 1 1
thumb in its course inwards the second phalanx is occasionally possible, by
approaches the little finger ; means of the deep head of the flexor brevis.
skimming the base of the The me(Han alsQ supplies in the hand
ringers. Then the little ringer , rr
is bent inwards to reach the the first two lumbricales, but paralysis of
extremity of the pulp of the t hese muscles is fully compensated for by
thumb. (Claude, Dumas, and . . r . . .
Porack, Presse Med., 10 June, integrity of the interossei and causes no
1915.) motor disturbance whatsoever.
Sensory Syndrome
The sensory region of the median comprises :
1. The external part of the palm of the hand, though without
reaching the outer side of the thumb ;
2. The palmar surface of thumb, index and middle finger : the
external half of the ring-finger ;
3. The dorsal surface of the second and third phalanges of the index
and the middle, and the external half of the ring-finger.
In the median, however, as in the ulnar, total anaesthesia is usually
MEDIAN NERVE
177
confined to a portion only of this region, almost always to the index ; it
gradually becomes less pronounced as we approach the regions of the ulnar
and the radial.
Figs. 152 and 153. — Anatomical region ot the median.
Figs. 154 and 155. — Usual topography ot" sensory disturbances of tin median. Three
diagrammatic zones: complete anesthesia, pronounced hypo-;isthesia, and slight
hypo-;esthesia.
Trophic Syndrome
Trophic disturbances of neuritis of the median, affect the palm of the
hand far less than do those of the ulnar; they are confined chieflv to the
12
178 NERVE WOUNDS
fingers, particularly the index and the middle finger ; they affect the thumb
to a less degree and the ring-finger but slightly. They act mainly on the
second and third phalanges as well as on the nails of these fingers, the
deformities of which are obvious and persistent.
Apart from the various neuritic disturbances we shall study later on,
we may note in simple lesions of the median, the cyanosis and redness
of the innervated fingers, chiefly the index ; dryness of the skin, or, on
the other hand, profuse sweats in the cutaneous region of the nerve, also
a tendency to chilblains.
Finally, in very rare cases, we may note the appearance, at the end of
the fingers, of ecchymoses, or occasionally of small ulcers, caused by various
mechanical or chemical irritants.
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.
CLINICAL FORMS OF LESIONS OF THE MEDIAN NERVE
In the case of the median, even more than of the ulnar, it is not easy to
differentiate between complete interruption and simple compression.
Muscular hypotonia is difficult to establish ; muscular atrophy of the
epitrochlear and thenar muscles is more rapid and pronounced in nerve
interruptions, but sometimes it is not easy to judge, by reason of the
preservation of the flexor carpi ulnaris and of the internal fasciculi of the
flexor profundus. The main signs of interruption are the early appear-
ance and the intensity of the electrical disturbances, the constancy of
anaesthesia and the fixity of formication which is found at the level of the
lesion.
We will study in succession :
1. Paralysis of the median above the epitrochlear muscles ;
2. Lesions of the median below the epitrochlear muscles ;
3. Dissociated paralysis of the median.
4. Neuritis of the median.
5. Causalgia of the median.
I.-COMPLETE PARALYSIS OF THE MEDIAN IN THE ARM
ABOVE THE EPITROCHLEAR MUSCLES
Paralysis of the median is not shown when at rest by any special
attitude. It is revealed solely by movement. Pronation is impossible,
however little resistance is offered to it ; flexion of the hand on the wrist,
which is very feeble, occurs only by means of the flexor carpi ulnaris ;
flexion of thumb, index and middle finger is impossible ; they remain
MEDIAN NERVE
*79
extended if the patient tries to shut his hand, whereas the last two fingers
are strongly flexed by the flexor profundus alone.
Fi<;. 156. — Paralysis of the median nerve. Complete interruption above the
epitrochlea. Maximum flexion of the fingers.
We must, however, qualify some of these statements.
On the one hand, the middle finger may often be slightly flexed,
being affected by movement of the ring-finger, on account of the apo-
FlG. 157. — Complete paralysis of the median nerve (resection and suture at the middle
third of the arm). The interossei are capable of flexing the rirst phalanx. Flexion ol
the last two, however, is impossible. (In this case, flexion of the middle is possible, by
the flexor profundus, which is sometimes supplied by the ulnar.)
neurotic slip which unites their extensor tendons on the dorsal surface of
the hand. It frequently happens that flexion of the middle finger is almost
complete when the ulnar supplies a branch to its flexor profundus.
180 NERVE WOUNDS
On the other hand, the interossei are capable of flexing the first
Figs. 158 and 159. — Complete paralysis of the median nerve. Impossible
to flex the index finger.
phalanx of index and middle finger on the metacarpus, but the last two
phalanges remain extended.
It is easy to eliminate
the cause of error produced
by the action of the inter-
ossei and to show that flexion
of the second and third
phalanges is impossible by
requesting the patient to
intertwine the fingers of
both hands and then to close
them. It is noticed that
the index finger and the
thumb remain extended,
that flexion of the middle
finger is slight, whereas the
last two fingers can be flexed
strongly. (Pitres.)
Again, if the patient is
ordered to flex his hand on
his wrist and his fingers on
his hand, we notice exten-
sion of the index finger;
this would seem to be an
irrefutable sign of paralysis
Fig. 160.— Paralysis of" the median (first sign). On
the left side, the patient cannot bring the thumb
in front of the middle finger as on the right side.
(Claude, Dumas, and Porack, Presse Med., 10
June, 1 9 15.)
of the median. (M. and Mine. Dejerine.)
Even more simply we may firmly fix the first phalanx of the index
MEDIAN NERVE
1N1
finger and ask the patient to flex the others ; alternatively, his hand resting
flat on a table, the patient is asked to scratch the table with the nail of the
index finger. (Pitres and Testut.)
Finally, the thumb has lost all its power of flexion and opposition. If
the patient is ordered to close his fist, it is found that the thumb remains
extended and cleaves to the index finger instead of being flexed in
opposition in front of the other fingers (first sign). (H. Claude.)
There may sometimes be observed manifest dissociation in paralysis of
the epitrochlear muscles ; the pronator radii teres, the flexor carpi radialis,
and the palmaris longus have partially retained their movements and still
FlG. i 6 i. —Dissociated paralysis of the median. Integrity of the pronator radii teres,
the flexor carpi radialis, and the palmaris longus, which become prominent at the
wrist.
preserve slight faradic contractility, whilst the flexors are paralysed. This
dissociation may be found in three forms.
1. As the result of lesion of the nerve at the bend of the elbow, below
the twigs destined for the pronator radii teres, the flexor carpi radialis and
the palmaris longus.
2. From lesion of the nerve at the level of the arm, giving rise to a
dissociated syndrome. We have observed this several times, but it cannot
be affirmed that lesion of the nerve is partial in all these cases. Indeed it
may be remembered that the anastomosis coming from the musculo-
cutaneous brings fibres of the fifth and sixth cervicals to the median, most
of these fibres, actual aberrant fibres of the external root of the median,
seem destined for the pronator radii teres and the flexor carpi radialis,
indeed we shall see (brachial plexus) that the external and superior root ol
the median evidently to a large extent supplies the pronator radii teres, the
flexor carpi radialis, and the palmaris longus.
182
NERVE WOUNDS
3. This dissociation is also noted.in the course of progressive regenera-
tion of the nerve ; the flexor carpi radialis, the palmaris longus, and the
pronator radii teres regain their movements before the other flexors.
II.— PARALYSIS OF THE MEDIAN IN THE FORE-ARM BELOW
THE EPITROCHLEAR MUSCLES
Lesion of the median in the fore-arm is indicated solely by paralysis of
the thenar eminence and by anaesthesia of the hand.
These disturbances are exactly similar to those found in total paralysis
of the median ; still, it is well to study paralysis of the thenar muscles a
little more closely, and to compare it with ulnar paralysis.
Fig. 162. — Atrophy of the thenar eminence in paralysis of the median.
If paralysis is of long standing, atrophy of the thenar eminence is very
obvious, but the paralysis is chiefly shown by atrophy of the abductor and
of the opponens ; it induces flattening of the thenar eminence ; a flat area
or even a depression running parallel to the first metacarpal, replaces the
normal projection. This atrophy is superficial ; it is not, as in ulnar
paralysis, atrophy of the deep muscular layers (adductors of the thumb and
deep head of the flexor brevis). Owing to integrity of the flexor longus
pollicis, flexion of the thumb is not abolished.
The only movement which is really absent is that of opposition ; still
it is sometimes difficult to discover this. Indeed, if the patient is asked to
touch with the extremity of the flexed thumb the extremity (if sonic other
finger, it is found that the movement is possible ; this is not done, all the
MEDIAN NERVE 183
same, by frankly setting the one against the other, it is effected by flexion
of the thumb in the hand and flexion of the fingers over its extremity ;
thumb and fingers no longer meet at the pulp, as in normal opposition, but
on their dorsal or lateral side ; it is a case of pseudo-opposition.
Finally, although the flexors are entirely retained, we must here note
Fig. 163. Fig. 16+.
Fig. 163. — Normal opposition in a healthy subject. The fingers are completely and
really opposed ; rotation of the thumb is complete.
Fig. 164. — Pseudo-opposition in a case of section of the median at the wrist. The
ringers are opposed at their sides. The thumb is flexed by its own flexor, supplied in
the fore-arm, far above the wound.
the frequency of their functional paralysis, a pseudo-paralysis caused by
ana-sthesia of the hand : no longer feeling his fingers, the patient thinks
that they are paralysed and does not even attempt to use them. We shall
return to this point when we discuss diagnosis.
III.— DISSOCIATED PARALYSES OF THE MEDIAN
The median, like the ulnar, may show partial lesions and dissociated
paralyses.
We have mentioned the relative preservation of the pronator radii
teres, the flexor carpi radialis, and the palmaris longus sometimes found even
in certain complete interruptions of the nerve in the upper part of the arm .
possibly in these cases the motor fibres originate in the anastomosis of the
musculo-cutaneous. All the same, more complete dissociations may be
found.
In certain cases, for instance, there is found to be complete paralysis of
1 84
NERVE WOUNDS
the flexors supplied by the median ; flexion of the index finger is impossible ;
flexion of the other fingers takes place solely through the fasciculi of the
flexor profundus which is supplied by the ulnar. The pronator radii teres,
however, the flexor carpi radialis, the muscles of the thenar eminence, and,
above all, the opponens have retained their movements ; the flexor longus
pollicis is weakened but not wholly paralysed.
In these cases, the lesion affects the inner part of the nerve.
We have noted three cases of this dissociated form ; the first two were
Fig. 165. Fig. 166.
Fig. 165. — Dissociated paralysis of the median nerve. Paralysis of the flexors. Integrity
of the flexor carpi radialis, of the palmaris longus, of the pronator radii teres, and of
the opponens. Wound in the middle of the arm affecting only the inner part of the
nerve.
Fig. 166. — Fascicular topography of the median. The inner part supplies the flexors.
The outer part supplies the pronator radii teres, the carpi radialis, the palmaris longus,
and the thenar eminence.
accompanied by no sensory disturbance whatsoever ; in the third, there
was somewhat pronounced anaesthesia of the distribution of the median.
In other cases, where the lesion affects the nerve at its external border,
it is rather the muscles of the thumb, the pronator radii teres and the
flexor carpi radialis that are paralysed, the existence of sensory disturbances
is not invariable.
It would thus appear that the fibres destined for the pronator radii
teres, the flexor carpi radialis, the flexor pollicis and the muscles of the
thenar eminence occupy the outer part of the median nerve.
The fibres that supply the flexors, on the other hand, are the most
internal.
MEDIAN NERVE
185
The sensory fibres probably hold an intermediate position, since either
of these motor syndromes may involve injury to them.
According to the researches of Pierre Marie, A. Gosset and H. Meige,
on applying local electrical stimulation to the nerve trunks, there are in the
median nerve, in the arm, four distinct groups of motor fibres :
Pronator muscles in the antero-external region of the nerve.
Thenar muscles in the posterior region.
Flexor muscles of the carpus in the postero-internal region.
Flexors of the fingers in the antero-internal region.
IV.— NEURITIS OF THE MEDIAN
An essential distinction must be drawn between neuritis of the median,
accompanied by considerable trophic disturbances, and neuralgia of the
median, both frequent and distinctive, to which the name of causalgia has
been given.
Nerve irritation of the median is
characterised, as is that of all other
nerve trunks :
1. By spontaneous and often
very acute pain ;
2. By pain on pressure of the
nerve trunks and muscular bellies ;
3. By painful hypo-aesthesia or
even by cutaneous hyper-aesthesia ;
4. By important trophic disturb-
ances culminating in gr'iffe of the
median.
We again find in these cases
cutaneous trophic disturbances, scaly
desquamation of the skin, and fibrous
infiltration of the dermis ; but we
must especially note two orders of
symptoms : disturbances of the nails
and the formation of griffe.
The nails of thumb, index and
middle finger are always consider-
ably affected in neuritis of the median.
In the pronounced form, the nails are striated, both longitudinally and
transversely, bent into actual claws ; they grow extremely fast, and their
rapid development raises between the nail and the digital pulp a small
cutaneous swelling which, provoked and increased by the growth of the
nail, is frequently the seat of somewhat acute pain.
Trophic disturbances of the nails in neuritis of the median are
absolutely constant and very well defined. Sometimes even, in slight
167. — Sub-ungual swelling in
neuritis of the median,
1 86 NERVE WOUNDS
nerve irritation, the nails alone are affected, and it is their special incur-
vation that enables us to recognise the existence of this irritation.
Griffe of the median, in neuritis of this nerve, is far from being as
Fig. i 68. — Griffe of the median caused by neuritis. Deformity of the nails. Glossy
skin. Atrophy and fibrous infiltration of the last two phalanges, especially of the
index.
constant and intense as ulnar griffe. Still, it is occasionally found, or
suggested at all events.
It consists of fibrous contraction of the flexor tendons and synovial
Fig. 169. — Incurvation of the nails in slight neuritis of the median.
Immobilisation of the finger in extension.
sheaths, immobilising thumb, index and middle finger in moderate though
irreducible flexion. This flexion is most pronounced in the last phalanges ;
contraction of the palmar aponeurosis is but faintly perceptible and its
MEDIAN NERVE 187
relative integrity contrasts with the intensity of its disturbances in neuritis
of the ulnar.
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. Neuritis of the median
in these cases somewhat resembles neuritis of the musculo-spiral : but
whereas articular sclerosis is more marked in the case of the first digital
articulation, on the other hand, when the musculo-spiral is involved in
neuritis of the median, it is the second and third digital articulations that
arc specially affected.
As in all other cases of nerve irritation, the fibrous sequelae left by
Fin. 170. — Neuritic griffe of the median.
irritation of the median persist long after the paralysis has been cured and
may even terminate in irreducible deformity.
Neuritis of the median is found both in lesions of the nerve, in the
arm, and in irritations below the elbow, even at the wrist.
It may exist apart altogether from paralysis, but, as a rule, in such
cases, it somewhat resembles, in the slight degree of trophic disturbances
and the intensity of painful phenomena, neuralgia of the median in its
causalijic form. This we shall now study.
V.— CAUSALGIA OF THE MEDIAN NERVE
Nerve irritations of the median assume with the utmost frequency and
intensity the type of the causalgia of Weir Mitchell ; to such an extent
is this so, that causalgia has been regarded as peculiar to this nerve.
Whilst this fact may not be altogether correct, whilst other nerves,
particularly the sciatic and chiefly the internal popliteal, are capable of
presenting the same disturbances, none the less is it true that causalgia of
the median is by far the most frequent and characteristic.
NERVE WOUNDS
It almost invariably accompanies slight lesion of the nerve, without
paralysis or anaesthesia, but appearing all of a sudden and accompanied by
almost purely painful symptoms and a minimum of trophic disturbances.
*****
Immediately after the wound pain manifests itself, but it gradually
increases during the following days, usually reaching its culminating point
after ten or twenty days.
Patients complain of terrible, intolerable, persistent, paroxysmal pains
both day and night ; these pains are essentially localised in the hand, but
they spread over the upper part of the arm, even though the wound is in
the fore-arm or the wrist.
The pain is a special and a violent one, characterised by a sensation of
persistent burning, whence the name of causalgia (icavaig, burning).
Cold, heat, the slightest con-
tact, cause the most atrocious
pain. What patients most dread
is contact with the air and dryness
of the hand ; tepid water often
relieves them, and we see them
wrapping round their hands
moist cloths which they con-
stantly renew. It is also to be
noted that profuse perspiration
of the hand frequently takes
place.
It is not only cutaneous ex-
citations of the hand that cause
painful paroxysms, movement of
any kind is painful ; simple
swinging of the hand when
walking causes intolerable re-
crudescences in these patients.
Strong emotion, an approaching
carriage, an unexpected sound, the banging of a door, a brilliant light, the
dizzy sense of void in a staircase ; any of these may bring on a terrible
and painful crisis.
Thus we find in these patients special symptoms : emaciated by reason
of insomnia and loss of appetite, they are gloomy and peevish, they will
neither talk nor go outside, they seek solitude, silence and obscurity ; they
walk slowly, with short steps, to avoid all shock ; if any one approaches
them, they slink away, carefully protecting the hand from all contact by
concealing it behind the back, or placing the other arm round it as a
shield. The hand is carefully enveloped either with a glove or with wet
cloths, which some of them keep renewing, even during conversation.
If these patients are examined, we are surprised to find that there is
Fig. 171. — Position of the hand at rest.
This is not a paralytic posture ; but im-
mobilisation caused by pain. (Dejerine.)
MEDIAN NERVE
189
no paralysis ; the hand is simply immobilised as a result of pain. Nor is
there complete anaesthesia, though often very intense and painful hyper-
esthesia ; more than this, whereas the slightest touch of the skin causes
intolerable suffering, firm pressure on the integuments is not very painful,
pressure on the muscles of the fore-arm is not at all painful, that on the
nerve but slightly, except near the hand. It is excitation of the surface
that is painful, not deep excitation as in cases of neuritis.
Trophic and vaso-motor disturbances are insignificant and of a rather
special nature.
Usually the skin is not thickened as in cases of neuritis ; on the con-
trary it is thin, smooth and glossy, with an onion-rind appearance. It is
often red and almost always moist.
Fig. 172. — Topography of the disturbances of objective sensibility. These disturbances
extend beyond the cutaneous region of the median, a, Hyperesthesia to slight con-
tact (wisp of cotton wool). />, Hyperesthesia to pin-prick, c, Hypo-;tsthesia to heat.
Oblique hatching .- the heat is less distinctly felt. Horizontal hatching ; the heat is not
recognised as such. (J. and A. Dejerine and Mouzon, Presse Med., 8 July, 1915.)
There is neither sclerosis of the dermis, fibrous contraction nor
articular immobilisation ; the nails are curved as in neuritis, but they arc
thin and smooth, not thickened, split or striated. Moreover, the)- grow
rapidly and produce behind the pulp a slight cutaneous swelling which is
extremely painful.
After a few months there can be seen taking place considerable atrophy
of the extremities of index and middle finger, thin, tapering and conical
extremities which terminate in quite small and almost triangular nails.
Whilst the trophic disturbances usual in cases of neuritis are absent in
causalgia, special lesions are found from time to time ; we have seen small
subungual ecchymoses or more frequently small cutaneous phlyctens, com-
parable to sudamina which, on rupture, left a very painful punctiform
cicatrix. It would seem that the thinness and fragility of the integuments,
the constantly damp condition and perhaps more especially the maceration
190
NERVE WOUNDS
of the continually moistened epidermis, favour the appearance of these
trophic disturbances.
There are cases of causalgia in which neurotic lesions are more mani-
fest ; accompanied by dryness of the skin, scaly desquamation, fibrous
infiltration of the dermis and a tendency to ankylosis of the last phalanges.
Figs. 173 and 174. — Causalgia of the median nerve. Tapering of the fingers, atrophy,
thinness of the skin, profuse sweat. Sudamina followed by ulceration. Rapid growth
of nails and sub-iingual swellings.
Causalgia of the median is very refractory to treatment ; it continues
for eight, ten, or even fifteen months, before diminishing and finally
disappearing. Massage has no result whatsoever, galvanic electrical
stimulation with the positive pole, and iodine or salicylic ionisation cause
only a few hours' relief; in these conditions it may readily be understood
MEDIAN NERVE
191
that there has been strong temptation to practise resection and suture or
alcoholisation (Sicard) of the affected nerve.
At the same time, one hesitates before subjecting these patients, who
are not paralysed, to the risks of nerve suture.
Radiotherapy to the nerve itself or to the roots frequently alleviates
causalgia, but it only dispels the painful paroxysms and does not calm the
continuous dull pain.
Fig. 175. — Causalgia of the median nerve, with incurvation of the nails, conical atrophy
of the last phalanges, fibrous infiltration of dermis and digital articulations. (Com-
pare index and middle finger with the comparatively unaffected ring-finger.
Moreover, its effect is not constant.
At present, there is a tendency to regard causalgia as a sympathetic
syndrome. Undoubtedly vaso-dilatation or vasoconstriction of the skin,
profuse sweats, and the recrudescence of pain through emotion, call forth
the idea of sympathetic disturbances. (Leriche, Meige and Mine. Benisty.)
In causalgia caused by wounds at wrist or in the fore-arm, we have
found disturbances throughout the entire region of the cervical sympathetic,
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 ; there was also slight numbness of the surface
on the same side, a diminution of sweat, vaso-motor disturbances in the ear
on the affected side, manifestly proving the existence of reflex excitation
of the cervical sympathetic.
192
NERVE WOUNDS
All these facts may justify the intervention proposed by Leriche :
denudation of the brachial artery and resection of the sympathetic plexus
surrounding it. 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, either above the epitrochlear muscles, when flexion of the first
Figs. 176 and 177. — Pseudo-paralysis of the median, Lesion of the nerve in the tore-
arm. Cutaneous anesthesia and atrophy of the thenar eminence. Although the
flexors are intact, the patient cannot close his hand completely. Faradisation ot the
flexors readily produces movement. Cure effected by a single treatment.
phalanges by the interossei might incline one to believe in the possibility
of some slight action of the flexors, or below the epitrochlear muscles,
where all the disturbances are reduced to cutaneous anaesthesia and to the
loss of opposition of the thumb.
MEDIAN NERVE 193
Wounds of the fore-arm, in which the median nerve is affected, very
often cause, from injury to the muscles, a weakening or even complete
incapacity of the flexors of the fingers, that might erroneously be attributed
to nerve lesion.
To avoid this error, we must remember that the flexors receive their
nerve twigs very high up, immediately below the bend of the elbow ;
moreover, the muscles weakened by the wound retain more or less their
normal electrical reactions and above all their faradic excitability.
It is also known that there is frequently associated with these wounds
a certain degree of functional paralysis due to prolonged inaction.
Here we would point out a somewhat frequent cause of error, to which
allusion has already been made. We refer to functional paralysis of the
flexors of the thumb, the index and the middle finger, following lesion of
the median in the fore-arm and caused by anaesthesia of the hand.
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.
We need only contract the flexors by means of the faradic current to
recognise the functional nature of this paralysis, prove to the patient the
possibility of movement, and effect a speedy cure.
'3
CHAPTER IX
ASSOCIATED PARALYSIS OF THE MEDIAN
AND ULNAR NERVES
It is necessary to make a special study of the associated paralyses of the
median and the ulnar. 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.
Fig. 179. — Paralysis of the median and the ulnar. 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 we note the association of the two paralytic syndromes,
also complete loss of the movements of flexors and interossei.
PARALYSIS OF MEDIAN AND ULNAR NERVES 195
Atrophy of the epitrochlcar muscles is complete ; the massive atrophy
of the thenar and hypothenar muscles produces the " flat hand " appearance.
Owing to atony of the
flexors and interossci, 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 third.
Particularly important
are the curious substitu-
tionary movements found
in most cases and first
mentioned by H. Claude.
Flexion of the hand on
the wrist is theoretically
suppressed ; all the same,
it is for the most part
possible, by substitution of
the extensor ossis meta-
carpi pollicis and the short extensor of the thumb.
Finger-flexion is logically impossible. Patients, however, are capable
of performing certain flexion movements ; to such an extent is this the case,
that it is difficult to believe that both nerves are paralysed.
They succeed in flexing the fingers by
forcibly raising the hand with the radial
extensors ; the effect of this hollowing of the
hand is to stretch the flexor tendons on the
pulley, as it were, of the radio-carpal articu-
lation, and consequently to exercise traction
on the fingers, in a purely mechanical way.
Again, in raising the hand, the patients
allow their fingers to droop under the action
of gravity, and this still further emphasises
the flexion attitude. This may be seen by
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.)
and mechanical traction of the
flexor tendon*.
1"k.. 1 S 1 . — Pseudo-flexion or the
fingers. In paralysis of the
median and the ulnar, by torci-
ble straightening of the carpus turning upwards the palm of the hand; the
action of gravity ceases, and the fingers,
being flexed only by the hollowing of the
hand, fall back into a state of moderate flexion.
It is 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 is
observed the progressive appearance of a special four-fingered g)'tjff''y supple
and reducible, characterised by flexion of the last two phalanges on the
196
NERVE WOUNDS
first : it is produced by tone of the flexors of the fingers, deprived of the
antagonism of the interossei, extensors of the last two phalanges.
Figs. 182 and 183. — Paralysis of the median and the ulnar in course of regeneration.
The " flat " hand has become transformed into a four-fingered griff e once the flexors
have regained their tone. (Soft and reducible griffe.) Note the projection ot the
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 emi-
nences, atrophy of the interossei, and
flexion of the last two phalanges, all give
the hand the typical appearance of the
" ape-like hand."
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
the median from the outer cord of the brachial plexus. Its fibres arise
almost solelv from the fifth and sixth cervical roots.
Branch to brach. ant.
Anastomosis of median an
musculo-cutaneous
Musculo-cutaneous nerve
Musculo-spiral nerve
Musculo-spiral (external branch)
Musculo cutaneous nerve
Branch to the coraco-brachialis
Internal cutaneous nerve
Branch to the biceps
Median nerve
Ulnar nerve
Internal cutaneous nerve (internal
branch)
Anterior aspect.
Fig. i 86. — Deep nerves of arm (after Sappey). The biceps has been resected
to lay hare the musculocutaneous nerve.
At its origin in the armpit, the musculo-cutaneous nerve is situated
above and outside the median and the axillary artery. It remains
adherent to the median, as far 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
brachialis anticus, covered by the biceps, supplying motor branches to
these three muscles.
It is under the biceps that the anastomotic branch breaks away, uniting
the musculo-cutaneous to the median nerve ; rising again obliquely it
enters this nerve, reaching it at the middle third of the arm.
Probably it often brings to the median aberrant motor fibres issuing
from the fifth and sixth cervical roots.
Posterior surface. Anterior surface.
Fig. 187. Fig. 188. Fig. 189.
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 nerve appears on the external
surface of the biceps, plunges underneath the edge of the supinator
longus, and becomes sub-cutaneous near the bend of the elbow ; it then
divides 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
[99
The nerves to the biceps.
The nerves to the brachialis amicus.
2. Beyond the biceps, the musculo-cutaneous is no more than a sensory
nerve where two parallel branches of the bifurcation supply the antero-
ihternal 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. 191.
Fig. 190. — Substitution of the paralysed musculo-eutaneous by the musculo-Bpiral.
Energetic flexion of the fore-arm on the arm by the supinator.
Fig. 191. — Muscles supplied by the musculo-cutaneous. Coraco-brachialis biceps ;
brachialis amicus. The deltoid is cut in order to expose the deep muscles.
latter about the middle of the arm. It seems to be proved that, speaking
generally, this branch brings to the median supplementary fibres of the
fifth and sixth cervical roots ; it mav fail in this; the thinner the external
head of the median, the more developed this branch is.
200 NERVE WOUNDS
PHYSIOLOGY— PARALYSIS OF THE MUSCULO-CUTANEOUS
Motor Syndrome
The musculo-cutaneous is the nerve whose sole function is to supply
the flexors of the fore-arm on the arm.
Its interruption determines paralysis and atrophy of the coraco-
brachialis, the biceps and the brachialis anticus ; these last two are flexors
of the fore-arm on the arm.
It must not be imagined that paralysis of the musculo-cutaneous does
away with the flexion of the elbow. This is still possible, even forcibly,
by the supinator longus (musculo-spiral), the flexor role of which is thus
proved.
Paralysis of this nerve may thus easily be disregarded if we confine
ourselves to making a simple flexion of the fore-arm without endeavouring
to obtain real contraction of the biceps and without exploring its electrical
reactions.
Sensory Syndrome
The musculo-cutaneous supplies the integuments of the antero-
external part of the fore-arm and passes slightly on to its postero-external
surface.
Nevertheless, we must not expect to find so extensive a state of
anaesthesia in lesions of this nerve. The musculo-spiral behind, and the
internal cutaneous on the inner side, overlap it considerably and largely
reduce the region of complete anaesthesia, which is restricted to a tract
extending over the antero-external part of the fore-arm.
CHAPTER XI
THE CIRCUMFLEX NERVE
The circumflex nerve is generally regarded as a collateral branch of the
brachial plexus.
By reason of its size and importance, however, we may, with Sappey,
regard it as a terminal branch of this plexus, becoming detached along
with the musculo-spiral from the posterior secondary trunk. Most of its
fibres originate in the fifth cervical root.
Supra-scapular nerve
Branch to the supra -
spinatus
Branch to the sub-
spinatu;
Muscular branch
Branch to the teres
minor
Muscular nerve
Cutaneous nerve to
shoulder
Fig. 192. — Circumflex and supra-scapular nerves. (After Sappey.)
It springs from the brachial plexus, about the middle of the axilla ; at
this level it is situated behind the axillary artery, and outside the musculo-
spiral nerve.
It immediately proceeds downwards and outwards, and passes towards
the posterior part of the shoulder accompanied by the posterior circumflex
artery ; it passes into the interspace circumscribed by the neck of the
humerus outwards and forwards, the long head of the triceps within and
behind, the lower edge of the subscapulars and of the teres minor above,
the upper border of the teres major below (quadrilateral square of
Velpeau).
It thus passes round the posterior surface of the surgical neck of the
humerus and reaches the deltoid on its deep surface.
202
NERVE WOUNDS
Branches
Apart from the articular branches and from certain fibres supplied to
the subscapulars, the only important offshoots supplied by the circumflex
are the deltoid branches and the cutaneous branch to the shoulder.
I. The deltoid branches issue from the circumflex nerve after it has
Supra-acromial branch
Circumflex nerve (cutan-
eous branch)
Muscitlo-spiral nerve (ex
cut. br.)
Lesser internal cutaneous (ext.
branch)
Circumflex nerve (cut. br.)
Second intercostal nerve
Third intercostal nerve
Musculo-spiral nerve (int. cut.
br.)
-Internal cutaneous (post, branch)
Internal cutaneous neive (ant.
branch)
Musculocutaneous nerve
LeVeU-LE S/4LLE*
Posterior aspect.
Fig. 193. — Superficial nerves of shoulder, arm and elbow. (After Sappey.)
reached the neck of the humerus. A distinction is made between the
ascending and the descending branches, which successively become
detached to supply the different portions of the deltoid.
This distribution is arranged in vertical segments, from behind for-
wards. Thus we see that certain lesions of the nerve, on the external
surface of the shoulder, for instance, may produce dissociated paralyses of
the circumflex ; the anterior and exterior fasciculi, clavicular and acromial,
are paralysed, whilst the posterior scapular fasciculi are untouched.
THE CIRCUMFLEX NERVE
203
2. The cutaneous nerve of the shoulder is a collateral sensory branch,
which breaks away from the circumflex after its passage into the quadri-
lateral space ; it proceeds downwards and outwards, and emerges between
the deltoid and the long head of the triceps. Then it divides into
ascending and horizontal branches which supply the cutaneous covering
for the shoulder, and in descending branches which are distributed over
the integuments of the external surface.
PARALYSIS OF THE CIRCUMFLEX
Paralysis of the circumflex is not met with in direct traumatisms of the
nerve only, it also appears in fractures of the surgical neck of the humerus
by embedding or compression of the
nerve : it may follow dislocation of the
FlG. 194. — Paralysis of the circumflex. Atrophy
of the deltoid.
FlG. J95. — Motor area <>t t lu
circumflex.
shoulder, owing to traction on or contusion of the nerve; all the same,
it would appear that in most of these cases we are dealing with the lesion
of the upper roots of the brachial plexus, stretched or torn away by the
dislocation (Duval and Guillain) ; in reality, they are cases of root
paralysis of the brachial plexus, affecting the fifth cervical root.
204
NERVE WOUNDS
Lesions of the circumflex are shown solely by paralysis of the deltoid
and by sensory disturbances of the shoulder.
Paralysis of the deltoid produces loss of power to raise the arm out-
wards (by means of the acromial fasciculi), forwards (clavicular fasciculi),
and backwards (scapular fasciculi).
The disturbances thus produced are all the more serious because sub-
stitutionary movements scarcely exist at all in the case of the deltoid.
The supra-spinatus alone is capable of slightly raising the arm outwards
and forwards, with rotation inwards ; this movement is extremely feeble,
and is incapable of introducing any effective substitution for paralysis of
the deltoid.
The arm remains hanging almost loose alongside the body ; in vain
does the patient attempt to raise it ; he contracts his shoulder muscles and
the supra-spinatus succeeds in making only a faint
movement of abduction ; he contracts the serratus
magnus, but the swinging movement imparted to
the shoulder-blade is nullified by the utter flaccidity
Figs. 196 and 197. — Anatomical sensory topography
of the circumflex nerve (cutaneous nerve of the
shoulder).
Fig. 198. — Actual anesthe-
sia in section of the cir-
cumflex.
of the deltoid ; finally, he partially detaches his arm artificially, by raising his
shoulder and bending his thorax in such a way that the arm is, as it were,
raised by the ribs on which it is resting.
At the same time atrophy of the deltoid flattens the shoulder and
relaxes the joint capsule, which often exhibits an abnormal degree of
laxity.
SENSORY DISTURBANCES
Sensory disturbances are somewhat reduced in paralysis of the cir-
cumflex. Seldom do we find complete anaesthesia ; as a rule, we simply
have more or less pronounced hypo-aesthesia of the external surface
of the shoulder.
CHAPTER XII
INTERNAL CUTANEOUS NERVE AND LESSER
INTERNAL CUTANEOUS NERVE
The internal cutaneous nerve and the lesser internal cutaneous are very
seldom affected separately ; on the contrary, they often share in the lesions
of the median and the ulnar, on the inner surface of the arm.
Supra-acromtal branch
Lesser int. cut. N.
1 2nd intercostal
Int. cut. N. (upper arm branch)
Int. cut. N.
Cut. br. of shoulder
( Post, branch
I. Ant. branch
Ulnar nerve
Musculo-spiral nerve (ext. cut. br.)
Muse. -cut. N.
Mus.-spir. N. (ext. cut. br.)
Anterior aspect.
Fig. 199.— Cutaneous nerve of shoulder and arm. (After Sappey.)
These are exclusively sensory nerves, originating in the lower secondary
trunk slightly internal to the ulnar.
The internal cutaneous descends to the inner part of the arm internal
2o6
NERVE WOUNDS
to the median nerve, in front of the ulnar nerve ; on reaching the middle
of the arm, it perforates the deep fascia and becomes superficial. 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
part of the fore-arm.
At the base of the axilla, it supplies the cutaneous branch to the upper
Mus.-spir. N. (ext. br.)
Musculo-cutaneous N.
Mus. cut. N. (ant. br.)
Mus. cut. N. (post, br.)
Mus. cut. N. (ant. br.)
Anastom. of mus. cut. and radial $
Collar
pollic. J
Int. cut. N. (brachialis anticus,
ext. br.)
Int. cut. N. (ant. branch, inter-
nal twig)
Anastom. of int. cut. and ulnar
Palm. cut. br. of median
Digital collateral trunks
Anterior aspect.
Fig. 200. — Superficial nerves of fore-arm and hand. (After Sappey.)
arm, which is distributed over the inner surface of the arm, as far as the
bend of the elbow.
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
arm) and right to the level of the epitrochlea.
A lesion of the internal cutaneous, usually associated with that of the
median and more especially of the ulnar, is shown by slight hypo-aesthesia
of the inner surface of the fore-arm.
Only lesions which involve the nerve in the neighbourhood of the
axilla are accompanied with hypo-aesthesia on the inner surface of
INTERNAL CUTANEOUS NERVE
207
the arm ; and even this hyperesthesia is greatly lessened owing to
the proximity of the lateral cutaneous branches of the second and third
intercostal nerves.
Musculo-spiral N. (ext. br.)
Muse. cut. N. (post, branch)
R;ul. N. (am. branch )Tj ;'
Int. cut. N. (post, branch)
Int. cut. N. (ant. branch)
GHn > Ulnar nerve (dorsal branch)
Rail. N. ^collat. br.)-] Jl^fh<
I if
Posterior aspect.
Fig. 201. — Superficial nerves of fore-arm ami hand. (After Sappey.)
208
NERVE WOUNDS
Figs. 202 and 203. Fig. 204.
Figs. 202 and 203. — Cutaneous topography of the internal cutaneous and the lesser
internal cutaneous (oblique hatching). The perforating branches of the second and
third intercostal nerves supply a triangular area on the postero-internal surface of the
arm, in the region of the lesser internal cutaneous.
Fig. 204. — Sensory disturbances in lesions of the internal cutaneous.
CHAPTER XIII
BRACHIAL PLEXUS
The brachial plexus consists of the fifth, sixth, seventh, and eighth
cervical roots and the first dorsal.
All these roots make their way towards the apex of the axilla, the
Fig. 205. — Brachial plexus and its collateral branches. (After Hirschfeld.) 1. Ansa
hypoglossi. 2. Pneumogastric nerve. 3. Phrenic nerve. 4, 5, 6, 7. Fifth, sixth,
seventh and tight cervical roots. 8. First dorsal root. 9. Nerve to the subclavius.
10. Nerve to serratus magnus. 11. Nerve to pectoralis major. 12. Sub-scapular
nerve. 13. Nerve to pectoralis minor. 14. Anastomoses of nerves of pectoralis major
and pectoralis minor. 15. Lower branch to sub-scapularis. 16. Nerve to teres major.
17. Nerve to latissimus dorsi. 18,20,21. L.I.C. 19. Its anastomosis with the lateral
cutaneous branch of" the second intercostal nerve. 22. Internal cutaneous nerve.
23. Ulnar nerve. 24. Median nerve. 25. Musculocutaneous nerve. 26. Musculo-
spiral nerve.
14
210
NERVE WOUNDS
higher ones taking an obliquely descending course, the lower ones following
a direction almost horizontal.
The brachial plexus thus spreads out into the sub-clavicular region in
the form of a triangle, with vertebral base and axillary apex.
Near the vertebral column, the roots of the plexus, set in tiers and
separated from one another, may be affected separately by traumatism,
whereas wounds in the axillary region almost invariably cause important
injuries that affect several trunks.
CONSTITUTION OF THE BRACHIAL PLEXUS
There are many individual variations in the constitution of the plexus ;
at the same time, we can give a tolerably simple diagrammatic description
of it.
I.— PRIMARY TRUNKS
The fifth and sixth cervical roots unite to constitute the upper trunk.
The eighth cervical and the first dorsal join to constitute the lower
trunk. The seventh cervical of itself forms the middle trunk.
II.— SECONDARY TRUNKS
Each of the primary trunks soon divides into two branches, the one
anterior, the other posterior.
Fie. 206. — Constitution of the brachial plexus.
The anterior branches of the upper trunk and of the middle trunk
unite to form the upper cord which is to produce the musculo-cutaneous
nerve and the external or superior root of the median.
The anterior branch of the lower trunk constitutes of itself the inner
BRACHIAL PLEXUS
21 I
cord, which produces the ulnar and the inner root of the median as well
as the internal cutaneous and lesser internal cutaneous.
The three posterior branches unite to form the posterior cord which
supplies the circumflex and afterwards constitutes the musculo-spiral
nerve.
Connexions of the Brachial Plexus
On leaving the intervertebral foramina, the roots of the brachial
plexus penetrate into the space separating the scalenus anticus from the
scalenus medius.
Then they cross obliquely the lower part of the supra-clavicular fossa
and converge towards the middle of the clavicle. It is slightly outside the
Pectoralis minor
Musculo-spiral ™
Fig. 207. — Connexions of the brachial plexus at the level of the axilla.
scaleni that the primary trunks appear. Thus the supra-clavicular area
is essentially that of the primary trunks and of their branches of division.
Below the clavicle are found the cords which soon produce the nerves
of the upper limb.
The important relation of the brachial plexus with the axillary
artery and vein are well known.
Situated at first external to, and a little behind the axillary artery,
which separates them from the vein situated more internally, the nerve
trunks are all around the artery ; the musculo-cutaneous is outside and
above, the median in front and outside, the musculo-spiral behind ; the
212 NERVE WOUNDS
ulnar runs between the artery and the vein ; the inner head of the
median, passing between the artery and the vein, crosses the anterior
surface of the artery.
Traumatisms which affect the brachial plexus will accordingly affect
the different groupings of nerve fibres, according to the level of the
wound.
We must remember that the brachial plexus may somewhat diagram-
matically be divided into four regions.
In the region of the scaleni, and even a little outside this zone, are
found the roots of the plexus.
The supra-clavicular fossa corresponds to the region of the primary
trunks.
Behind the clavicle and in the upper part of the axilla, are found the
secondary cords. In the lower axillary region appear the nerves of the
upper limb.
It is necessary to add that the nerve fibres all converge upon the axilla ;
at this level, lesions of the plexus will often be severe and very extensive,
affecting several nerve trunks and simultaneously affecting the axillary
vessels. Wounds of the supra-clavicular fossa, especially those of the
region of the scaleni, on the other hand, affect isolated nerve trunks ;
most frequently they induce partial lesions and dissociated root paralyses ;
the artery and the axillary vein, situated much lower, behind the clavicle,
are more rarely affected.
Branches of the Brachial Plexus
Along its course the brachial plexus sends out a certain number of
important collateral branches.
1. The nerve to the rhomboids which separates direct from the fifth
cervical root.
2. The nerve to the serratus magnus, which originates in the fifth
and sixth cervical roots, crosses the entire posterior surface of the brachial
plexus and descends along the mid-axillary line, adhering to the thoracic
wall.
3. The supra-scapular nerve, springing from the higher primary trunk
crosses the supra-clavicular fossa, 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. It thus penetrates
into the supra-spinous fossa, passes round the spine of the scapula and
terminates in the infra-spinous fossa.
It supplies the supra and infra spinati.
4. The upper branch to the subscapulars, originating in the upper
trunk.
5. The nerve to the subclavius rises generally in the anterior branch
BRACHIAL PLEXUS
213
of the upper trunk and supplies an anastomotic branch to the phrenic
(loop of Henle).
Supra-scapular net
Branch to supra-
spinatus
Branch to infra-
spinatus
l8Cu]ai I ranch
{ranch to teres minor
Circumflex nerve
Muscular branch
Cutaneous twig to
shoulder
Fig. 208. — Circumflex and supra-scapular nerves. (After Sappey.)
IV C
Infrnnr rervi'-jt
ganglion
Fig. 209. — Collateral branches of the brachial plexus.
6. The nerve to the pectoralis major (external anterior thoracic)
separates from the upper cord behind the clavicle.
7. The lower branch to the subscapular^.
8. The nerve to the teres major.
9. The nerve to the latissimus dorsi.
2i 4 NERVE WOUNDS
These three nerves become detached almost at the same level from
the posterior cord, near the origin of the circumflex.
io. The nerve to the pectoralis minor (internal anterior thoracic) has its
origin in the lower cord.
We must remember that the nerves to the rhomboids, to the supra-
spinatus and the infra-spinatus, to the subscapulars (upper branch) and to
the pectoralis major, originate successively from the fifth and sixth cervical
roots and from the primary and secondary trunks following them. They
thus belong to the higher root group.
The nerves to the latissimus dorsi and the teres major as well as the
lower branch to the subscapularis originate in the posterior cord.
The lower trunk supplies only the nerve to the pectoralis minor.
All the cervical roots, on leaving the intervertebral foramina, send out a
communicating branch to the cervical sympathetic. The branch from the
first dorsal root is particularly important, for it carries to the lower cervical
ganglion of the sympathetic the cilio-spinal fibres destined for the innerva-
tion of the pupil.
LESIONS OF THE BRACHIAL PLEXUS
The brachial plexus, like all the nerves, may be affected directly by a
wound, compressed by a foreign body, a bony callus, a cicatricial fibrous
mass, or even a simple hematoma of the supra-clavicular fossa or of the
axilla. But it may also be wrenched by traction on the upper limb, or
by violent downward traction of the shoulder, with or without dislocation.
Wounds of the brachial plexus may affect the roots or the primary
trunks as well as the secondary trunks and their branches of division.
Somewhat variable and often complex syndromes result, of which only
a very summary description can be given.
They differ mainly from the syndromes produced by wounds of the
peripheral nerve trunks in the fact that there is a different distribution
of motor and sensory disturbances. In the case of the roots and primary
trunks, 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.
We shall study in succession :
1. The radicular syndromes resulting from lesion of the roots or
primary trunks ; these result from lesions above the clavicle and affecting
the nerve trunks, either in the supra-clavicular fossa, or between the scaleni,
on the sides of the vertebral column, or even on a level with the inter-
vertebral foramina.
2. The plexus syndromes strictly so called, corresponding to lesions of
BRACHIAL PLEXUS
215
the secondary trunks and of their branches; these result from lesions
affecting the clavicular region or the upper part of the axilla.
We have already remarked that the roots and primary trunks are
frequently affected separately, producing partial paralysis of the brachial
plexus. The secondary trunks, on the other hand, closely adhering to one
Anterior view.
Posterior view.
Root
distribution.
Peripheral
distribution.
Root
istribution.
Fig. 210. — Root and peripheral sensory regions.
The radicular sensory regions are indicated by horizontal lines, parallel to the axis
of the limbs.
another, are more frequently affected as a whole and often produce
complete paralysis of the brachial plexus ; still, it is possible to find among
them syndromes of partial lesion. On the other hand, the close relations
of the secondary trunks with the axillary vessels explain the frequent
association of lesions and vascular syndromes which complicate strikingly
any clinical investigation.
I.— RADICULAR SYNDROMES (ROOTS AND PRIMARY TRUNKS)
The general character of the radicular syndromes is essentially the
root distribution of motor and sensory disturbances.
On the other hand, however, a great number of muscles are supplied
2l6
NERVE WOUNDS
by two and often three different roots ; consequently, partial paralyses of
these muscles will often be found.
Between the roots, too, there are extensive sensory substitutions ;
anaesthesia therefore resulting from radicular lesions is frequently less
obvious than anaesthesia from lesions of the trunks.
We shall describe diagrammatically three partial radicular syndromes,
corresponding to lesions :
1. Of the fifth and sixth cervical roots — upper radicular group comprised
in the upper primary trunk.
2. Of the seventh cervical root and the middle radicular trunk.
3. Of the eighth cervical root and the first dorsal — lower radicular
group, comprised in the lower radicular trunk.
I.— UPPER RADICULAR GROUP, FIFTH AND SIXTH
CERVICALS. (ERB-DUCHENNE SYNDROME)
I. Lesions of the upper radicular group are characterised essentially by
paralysis of the following muscles, supplied by its terminal branches ;
Deltoid.
Biceps.
Brachialis anticus.
Supinator longus.
Muscles of the shoulder.
Anterior view. Posterior view.
Fig. 21 1. — Upper radicular group. Motor topography.
Deltoid (circumflex nerve).
Biceps and brachialis (musculo-cutaneous nerve).
Supinator longus (musculo-spiral).
BRACHIAL PLEXUS
217
We need not insist on the nature of these paralyses, which have
already been studied. We simply call attention to the fact that flexion of
the fore-arm on the arm is completely suppressed, since the biceps and the
supinator longus are both paralysed.
2. There is also found paralysis of the following muscles :
Pectoralis major (clavicular head only).
Supra-spinatus and infra-spinatus.
Subscapularis.
Fig. 212. — Upper radicular paralysis from
wound in the'eervical region. Atrophy of
muscles of the shoulder, deltoid, supra-
spinatus, infra-spinatus, rhomboideus major
and minor, serratus magnus ; displacement
of the shoulder-blade.
Fig. 213. — Upper radicular paralysis from
wrenching of the fifth and sixth cervicals.
Atrophy of shoulder, of biceps, brachial is
amicus and supinator longus. Impossible
to flex the elbow or raise the shoulder.
Teres major, the nerves of which originate in the upper primary
trunk or its branches.
If the lesion affects the roots near their origin we even find paralysis ot
the serratus magnus, of the rhomboids, and the levator anguli scapulae.
There results atrophy of all the scapular muscles, displacement of the
shoulder-blade, giving the appearance of winged scapula (rhomboids and
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 magnus).
3. Finally, the upper radicular group partially supplies the following
muscles : coraco-brachial ; triceps ; radial extensors and supinator brevis ;
pronator radii teres and flexor carpi radialis ; the extensor ami flexor
muscles of the thumb.
2l8
NERVE WOUNDS
These muscles will be slightly weakened.
4. Sensory disturbances, which take place over an area parallel to the
axis of the limb, are never characterised by so complete an anaesthesia as
that of trunk lesions. We find a rather well-defined area of hypo-aesthesia
occupying the regions C-5 and C-6 ; it
extends over the outer surface of the arm
and the fore-arm ; it does not reach the
hand, but at most extends on to the base of
the first metacarpal.
The supinator jerk, from percussion of
the styloid process, is abolished.
II.— MIDDLE RADICULAR
SYNDROME
Paralysis of the seventh cervical or of
the middle radicular trunk, is essentially
characterised by paralysis of the muscles
supplied by the musculo-spiral nerve, with
the exception of the supinator longus, which
is untouched.
The triceps, weakened, is net completely
paralysed, for, as we remember, it is partially
supplied by the sixth cervical.
There also persist some very feeble
movements of the extensors and the extensor
ossis metacarpi pollicis (supplied partially by
C-6) and even slight movements of the
extensor indicis and the extensor minimi digiti (C-6 and C-8).
The syndrome produced is almost exactly that of saturnine paralysis
accompanied by similar integrity of the supinator longus.
The sensory region of the seventh cervical is extremely restricted. 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 olecranon reflex is abolished or inverted.
Fig. 214. — Upper radicular para-
lysis. Hypo-a^thesia C-5 and
C-6.
III.— LOWER RADICULAR GROUP (ARAN-DUCHENNE
SYNDROME)
Lesion of the eighth cervical root and of the first dorsal or of the
lower primary trunk is characterised by paralysis of the flexores digitorum,
the flexor carpi ulnaris, the interossei, the thenar and hypothenar eminences.
Summarising, we may state that the muscles supplied by the median
belong to the region of the eighth cervical, whereas the ulnar principally
carries fibres of the first dorsal.
BRACHIAL PLEXUS
219
Triceps (incom-
plete).
Radial extensors
Extensors of
lingers.
/!'
Fig. 215. — Middle radicular group (seventh
cervical). Motor topography.
Fig. 216. — Middle radicular group.
Sensory topography.
FlG. 217. — Middle radicular para-
lysis from wound of the cervical
region.
Considerable weakening of the tri-
ceps. Paralysis of the radial ex-
tensors and extensoics digitorum ;
attitude of musculo-spiral para-
lysis. (Lesion of the seventh
cervical.)
In this case the sixth cervical has
also been affected, for though the
deltoid is almost untouched, the
biceps is weakened and the supi-
nator longus almost completely
paralysed, whereas it ought to be
wholly untouched in paralysis
limited to the seventh cervical.
Integrity of movements in bending
the lingers. Weakening ot pro-
nation and flexion of the hand
(pronators, flexor carpi radialis,
palmaris longus, sixth and seventh
cervicals).
Hypo-aesthesia, somewhat more ex-
tended in an isolated lesion of the
middle radicular trunk, 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
220
NERVE WOUNDS
A lesion of C-8 and D-i reproduces very nearly the appearance of
associated paralysis of the median and the ulnar with flattened hand or
simian griffe, according as we have complete interruption or nerve
irritation.
Flexores digitorum.
Flexor carpi ulnaris.
Muscles of the
hand.
Motor topography.
Sensory topography.
Figs. 218 and 219. — Lower radicular group C-8 to D-i.
The muscles of the thenar eminence, however, particularly the abductor
pollicis, receive some fibres of C— 7 and even of C-6 ; the abductors of the
thumb seem to be supplied mainly by C-8, in
contradistinction to the other interossei, for which
D-i seems predominant.
Lastly the pronator radii teres and the flexor
carpi radialis receive, mostlv through the external
root of the median, fibres coming from C-6
and C-~. They are largely unaffected in lower
radicular paralyses.
Sensory disturbances are characterised in lower
root lesions by a band of hypo-a?sthesia of the
inner side of the limb.
On the internal surface of the arm, we note
the integrity of the triangular region supplied by
the second and third dorsals.
Into this tract of hypo-assthesia, however, on the inner side of the arm,
Fig. 220.
graphy.
hand.
-Motor topo-
Muscles of the
BRACHIAL PLEXUS 221
there fits the triangular zone responding to the second and third dorsal
roots.
The ulnar periosteal reflex is abolished.
OCULO-PUPILLARY SYMPATHETIC SYNDROME
It may be remembered that the communicating branch supplied to the
lower cervical ganglion by the first dorsal root carries to the cervical
sympathetic the fibres of the cilio-spinal medullary centre.
Fig. 221. — Lower radicular paralysis from wound in lower cervical region, with fracture
of the clavicle. Integrity of the deltoid, biceps, supinator longus, triceps and extensor
muscles. Paralysis and atrophy of the epitrochlear muscles ; persistence of the move-
ments of flexor carpi radialis and especially of the pronator radii teres. Paralysis and
atrophy of all the muscles of the hand. The lesion, of a neuritic type, has determined
fibrous contraction of the (lexores digitorum and of the palmar aponeurosis ; trophic
disturbances of the nails.
If this branch is destroyed by traumatism, as is usually the case in
the traumatic wrenching of the roots, we have the oculo-pupillary
syndrome described by Mme. Dejerine-Klumkc. This consists of myosis,
enophthalmos and contraction of the palpebral fissure of the corresponding
eye. However, it is not found in the lower radicular lesions alone ; it may
be noticed after lesions higher up, affecting the upper cervical roots. But
in these cases it does not come from the radicular lesion itself; it is
222
NERVE WOUNDS
produced by direct lesion of the cervical sympathetic chain, affected by
traumatism at the same time as the cervical roots.
Total Radicular Paralysis
Total radicular paralysis — as produced mainly by tearing of the brachial
plexus owing to violent traction on arm or shoulder — is characterised by
Fig. 222. — Oculo-pupillary syndrome from lesion of the first right dorsal root
(Dejerine-Klumplce syndrome). Sinking in of the eye ; constriction of the palpebral
fissure, myosis.
complete paralysis of the upper limb. Anaesthesia is complete on hand and
fore-arm, there is sensation, however, 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.
The oculo-pupillary phenomena previously described (first dorsal)
naturally form part of this syndrome.
II.— TRUNK SYNDROMES OF THE BRACHIAL PLEXUS
The syndromes produced by lesions of the secondary trunks and their
branches of division closely resemble peripheral syndromes.
Three partial types may be described :
i. Syndrome of the upper secondary trunk, corresponding to paralysis
of the musculocutaneous and of the outer head of the median.
2. Syndrome of the posterior secondary trunk (musculo-spiral circumflex
trunk), characterised by complete paralysis of the circumflex and the
musculo-spiral.
3. Syndrome of the lower secondary trunk, corresponding to paralysis
of the ulnar and of the inner head of the median, along with lesion of the
internal cutaneous, and of the lesser internal cutaneous.
As we see, these syndromes consist of the associated paralysis of two or
more peripheral nerves.
BRACHIAL PLEXUS
223
We must lay stress on the topography of the inner and outer heads of
the median. In paralysis of the upper secondary trunk (outer head of the
median) we have found complete paralysis of the pronator radii teres and
almost complete paralysis of the flexor carpi radial is, accompanied by
weakening of the flexor pollicis and of the opponens.
Again, in another case of lesion of the lower secondary trunk (inner
head of the median), there was paralysis of the flexores digitorum, with
preservation of some degree of flexion of the thumb and of opposition,
Fig. 223. — Syndrome of the upper
secondary trunk comprising the outer
head of the median.
Fig. 224. — Syndrome of lower
secondary trunk comprising the
inner head of the median.
almost complete integrity of the flexor carpi radialis and complete integrity
of the pronator radii teres.
The cases, moreover, of partial lesion of the brachial plexus behind the
clavicle and at the level of the axilla are not very frequent ; more often we
find important lesions affecting almost all the branches of the plexus. Still,
these branches are unequally affected, and, as time goes on, we may find
that complete paralysis at the outset becomes dissociated paralysis when the
less affected branches have resumed their functions.
Finally, association with vascular lesions is extremely frequent,
introducing into the clinical picture the complication of more or less
pronounced symptoms of iscluemic paral} sis.
224 NERVE WOUNDS
In this chapter we have contented ourselves with giving a general
and systematic summary of the syndromes of the brachial plexus. It is
possible, of course to find the most diverse associations ; we also meet with
every clinical variety corresponding to the nature of the lesion : syndromes
of complete interruption, of compression, nerve irritation forms, or simple
neuralgic syndromes.
There is no need to describe them ; their characteristics are exactly
the same as those of the various peripheral syndromes.
CHAPTER XIV
ISCHEMIC PARALYSIS OF THE UPPER LIMB
Ischemic paralysis of the upper limb is too frequently connected with
nerve wounds, and even when clearly defined is so difficult to diagnose
that we feel compelled to devote an entire chapter to it.
As a rule, it follows obliteration or ligature of a large artery, e.g.
subclavian, axillary or brachial artery. Nevertheless, we have found
ischemic paralysis following obliteration of the radial and ulnar arteries, we
have even met with a very singular case, after obliteration of the radial
artery in the anatomic snuff-box, accompanied by ischemia of hand ami
fingers.
Ischemic paralysis may also be seen after prolonged contraction of the
upper limb ; plaster of Paris applied too tightly is the most frequent cause
of such paralysis.
The mechanism of ischemic paralysis caused by obliteration of an
arterial trunk is far from being clear. Only a few obliterations of arteries
are accompanied by ischemic phenomena. For instance, out of thirty-two
cases of ligature of the axillary and sub-clavian, we have found no more
than five cases of genuine ischemic paralysis, some others complained of
slight signs of ischaemia, probably transitory ; most of them showed no
disturbance whatsoever.
In a similar lesion, such as ligature of the axillary, the extent of the
ischaemic region may vary considerably ; we have seen paralysis affect only
the hand or rise as far as the elbow.
In these cases, the integrity and distribution of the collateral
circulation constitute an important individual factor. In most cases tree
from paralysis, we quickly observe the reappearance of the radial pulse,
momentarily suppressed by ligature ; the arterial blood-pressure becomes
almost normal.
On the other hand, we sometimes find cases where arterial anastomoses
are lacking, where the radial pulse does not reappear ; nevertheless,
there are but few ischaemic phenomena, or none at all. For instance, we
have seen two patients who, three months previously, had submitted to
ligature of the axillary ; in both cases the radial pulse was suppressed ;
both had almost identical vascular tension, viz. scarcely any at all ; and
yet the symptoms observed were totally different.
*5
226 NERVE WOUNDS
By the Pachon sphygmomanometer, the first had a tension of 1 7-8 on
the healthy side ; of 9-8 with scarcely any oscillations on the ligature
side ; however, there was but slight cyanosis and cooling of the hand.
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, though
perceptibly stronger than in the former case ; he presented an instance of
complete ischemic paralysis accompanied by fibrous transformation of the
hand.
Probably the elasticity of the vessels, the presence or absence of
atheroma, the phenomena of vaso-motor spasms play an important part in
these cases, as well as the nerve lesions so often associated with arterial
lesions.
In addition to real ischaemic paralysis, mention must be made of the
more or less obscure syndromes of ischaemia from arterial obliteration which
often accompany nerve lesions : 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.
CHARACTERISTICS OF ISCH/EMIC PARALYSIS
We may describe two phases in the evolution of ischaemic paralysis.
1. In the first phase we note cedematous infiltration of the ischaemic
regions.
The hand is cold, either simply cyanosed or of the reddish tint of the
lees of wine; it is infiltrated with a soft swelling which is not confined
simply to the sub-cutaneous cellular tissue, but spreads over the muscles,
giving them a sort of pasty consistence ; the skin is infiltrated and
thickened, though remaining dull and dry.
Movement is not completely abolished, and the patient can still, though
with considerable trouble, move his fingers slightly. Passive movements
also are still possible, although the resistance caused by fibrous transforma-
tion of muscles and articulations is quickly developed.
Sensation has not altogether disappeared ; we even find, as a rule, the
coexistence of very marked hypo-aesthesia and of painful hyper-aesthesia :
patients complain of a numbed feeling in the hand ; all stimuli of touch or
pain-provoking heat are incompletely perceived, badly localised, and above
all, imperfectly differentiated ; but each of these stimuli gives rise to a
very painful sensation.
Deep sensation is somewhat better retained than superficial sensation.
Finally, these patients often complain of acute pains : burning or
freezing sensations with formication or numbness of the hand ; deep
pressure, cutaneous stimuli and cold more especially intensify these
sensations ; heat mostly calms them somewhat, and the patients carefully
wrap the hand in warm gloves or cotton-wool.
ISCHEMIC PARALYSIS OF THE UPPER LIMB 227
Sensory disturbances gradually increase from the root to the extremity of
the limb, their topography is therefore vaguely segmental.
2. In the second phase, we see fibrous transformation of the infiltrated
tissues.
After a few weeks, oedema
begins to diminish ; but the sub-
cutaneous cellular tissue, the
aponeuroses, the tendons, are gradu-
ally embedded in a veritable fibrous
mass ; the muscles become puffy,
they harden, atrophy, contract and
gradually acquire a woody con-
sistence.
The skin becomes smooth and
shiny, of a violet or even vivid
red colour, it is thin, dead-looking,
hard and adherent to the subjacent
tissues; the nails bend in like claws,
the fingers taper off and sometimes
become incurved, following the
fibrous contractions, the projections
of the muscular bellies disappear.
After the slightest traumatism we may find cutaneous ulcers of a dry
sloughy type, their cicatrisation is often a very long process.
All active or passive movements disappear progressively ; anaesthesia
Figs. 225 and 226. — Topography of anaes-
thesia in two cases of ischemic paralysis.
Fie. 227. — Ischaemic paralysis following ligature of the axillary. Fibrous
transformation of the hand.
appears and becomes complete ; the pain also calms down ; and the hand
is gradually transformed into a sort of fibrous, rigid, inert and insensitive
appendage.
In true ischemic paralysis the hand is habitually extended] the fin
228
NERVE WOUNDS
slightly flexed, but in the case of associated nerve lesion, it maybe flexed in
a fibrous griffe, which recalls, in pronounced or distorted form, the
neuritic griff e of the median or the ulnar.
Fig. 228. — Ischaemic paralysis following the crushing and obliteration of the
brachial artery. Fibrous transformation of the hand.
Too frequently ischaemic paralysis is incurable, but considerable improve-
ment may be obtained by permanent warm covering, hot baths, prolonged
massage and mobilisation and galvanic or faradic electrical stimulation.
Fig. 229.- — Ischaemic paralysis from lesion of the axillary with association ot nerve dis-
turbances. Fibrous hand, completely immobilised in the position ot ulnar griffe.
DIAGNOSIS
Ischaemic paralysis is distinguished from nerve lesions by the following
characteristics : —
I. Distribution of motor and sensory disturbances corresponding to no
peripheral nerve topography. On the contrary, it is segmentary.
ISCHEMIC PARALYSIS OF THE UPPER LIMB 229
All these disturbances are pronounced at the periphery and gradually
diminish towards the root of the limb.
2. The special puffy or wooded consistence of all the tissues.
3. Suppression of the radial pulse.
4. In some cases it is even possible to ascertain that there is no real
paralysis : a few imperfect movements continue for a long time : we find
Fig. 230. — Ischaemic paralysis from lesion of the brachial artery.
Associated with median griff e.
that the muscles are not really paralysed but are immobilised by fibrous
infiltration.
5. Electrical reactions likewise are somewhat different : there is no
polar inversion, but enormous hypo-excitability which speedily becomes
complete inexcitability ; as long as electrical excitation is capable of causing
muscular contraction, we can obtain this movement by exciting the nerve
from a distance or at the motor point, as well as by excitation of the
muscle itself.
PART III
LOWER LIMB
CHAPTER XV
SCIATIC NERVE
The sciatic is by far the most frequently affected nerve in the lower Limb.
The bulk of its trunk, the length of its course, the number and im-
portance of its branches which supply the greater part of _
the lower limb, render it particularly vulnerable.
ANATOMY OF THE SCIATIC NERVE
The lars:e sciatic nerve is the longest and most widelv
distributed in the human body.
It originates in the fourth and fifth lumbar roots,
through the medium of the lumbosacral cord, and more
particularly in the first, second and third sacral roots ; it
represents " the sacral plexus condensed in one nerve cord."
(Cruveilhier.)
All its original branches are united at the level of the
sciatic notch.
It passes round the ischial spine and descends in the
posterior part of the buttock between the ischium and
the greater trochanter, covered by the mass of the gluteal
muscles and the pyramidalis, and also below this muscle
by the lower part of the gluteus maximus.
It descends in the posterior part of the thigh into
the interspace comprised between the semimembranosus
and the semitendinosus within, and the biceps without.
It rests on the posterior surface of the femur which is
covered by the insertions of the adductors and by the
vastus externus.
It becomes superficial at the upper end of the popliteal
space, in the neighbourhood of which it divides into
its two terminal branches — the external popliteal and the internal
popliteal.
The level at which this division takes place is extremely variable ; it
232
NERVE WOUNDS
may be very high, sometimes these two branches rise as far up as the
pelvis, distinct from each other yet in close apposition, in gun-barrel
fashion.
Collateral Branches
Along its course, the trunk of the great sciatic nerve supplies :
i. The upper nerve to the semitendinosus, which arises very high up,
immediately below the tuberosity of the ischium.
Superior gluteal N.
N. to the pyramidalis
Inferior gluteal N.-l 'i
Posterior cutaneous N. (per. br.)
„ . ..,,., J WllH -t^M It Great sciatic N.
rostenor cutaneous N. (thigh)
Nerve to the semitendinosus ■flB KaBI^ / fl ; H N. to short head of biceps
N. to the semimembranosus ' Iffi/it^Ml Wsi§k V N " t0 '° ng head oi bice P s
'Um 'S'/ 'iBI JJSH 'wf
Nerve to the semitendinosus
Int. pop. N.
N. to int. head of gastrocnemius
Ext. saph. N
Int. pop. N.
xt. pop. N.
N. to ext. head of gastrocnemius
Fig. 232. — Sciatic nerve and its collateral branches in buttock and thigh.
(After Sappey.)
This is the reason why the semitendinosus is often untouched in lesions
of the sciatic.
2. The nerve to the long head of the biceps which appears at a very
variable level, most frequently in the middle region of thigh.
3. The nerve to the semimembranosus which originates at the same
level and often from the same trunk as the nerve to the biceps.
SCIATIC NERVE
233
Gluteus maximus'
Small sciatic nerve" -^
[
Int. pop. N.
Int. saph. N.
Ext. popl. N.
Int. saph, V.
Ramus communicans fibularis
Int. head of gastrocnemius
Int, saph. N.
V
4. The nerve to the short head of the biceps, the origin of which also
varies considerably, being usually a little below the nerve to the long head.
To these collateral
branches must be added
another supplied by the
sciatic to the adductor
magnus and the upper
articular nerve or the
knee.
There is no need to
dwell on the function of
these muscles, all being
flexors of the leg on the
thigh.
Sufficient to note that
the order in which these
branches breakaway from
above downwards ex-
plains the frequent weak-
ening of the biceps in
lesions of the sciatic,
whereas the semimembra-
nosus and especially the
semitendinosus are more
frequently untouched.
Terminal Branches
The division branches
of the sciatic nerve really
constitute two distinct
nerves, antagonists of each
other : the-external popli-
teal, the nerve of exten-
sion, homologous to the
terminal part of the
musculo-spiral, and the
internal popliteal, the
nerve of flexion, more
widely distributed and
representing both the
median and the ulnar.
Int. saph. N.
Ext. Saph. N.
Post. tih. N. (calcaneal branch) --
Posterior aspect
Fig. 233. — Superficial nerves of the lower limb. (Froi
two sketches by Hirschfeld.)
I.— EXTERNAL POPLITEAL NERVE
The external popliteal breaks away in the neighbourhood of the upper
end of the popliteal space.
234
NERVE WOUNDS
It proceeds along the internal border of the biceps, crosses the outer
tuberosity of the tibia covered by the external head of gastrocnemius, passes
behind the head of the fibula, and goes round the neck of this bone to
reach the antero-external region of the leg. At this level it is very super-
ficial, resting directly on the periosteum of the fibula where it may be
Fibular cut. br.
Ext. pop. N
N. to tib. ant
Ram. communicans iibularis
Anter. tib. N.
Muse -cut. N.
Anter. tib. N.
Ext. saph.
Anastom. of rami communi-
cantes tibialis et Iibularis
Exter. saph. N.
(terminal br.)
Muse. cut. N. (cut. br.)
Anastom. of ext. saph. and
musculo- cutaneous
Anastom. of ant. tibial, and
musculo-cutaneous
Fig. 234. — External popliteal nerve. (After Hirschfeld.)
involved in case of fracture ; it is immediately covered by the aponeurosis and
the skin.
It penetrates into the antero-external compartment of the leg, passing
along a musculo-fibrous canal formed by the origins of the peroneus longus.
Inside this canal it divides into its two terminal branches.
Collateral Branches
After sending out an articular branch, the external popliteal supplies :
1. The ramus communicans fibularis which descends upon the posterior
SCIATIC NERVE
2.45
sur
u.facc of the external head of gastrocnemius and is distributed to the skin
of the external and posterior region of the leg and the heel. At this level
it anastomoses with the external saphenous (internal popliteal).
2 The peroneal cutaneous branch or external cutaneous nerve of the
leg which appears at the same level as the former and descends outside it,
Ext. pop. N,
Peroneus longus
Musculo-cutaneous N.--
Extensor lonsr. digitorum >••-•
Exter. saph. N 41 /
-Anterior tibial N.
^Tibialis anticus
_.., Extensor propr. Iiallucis
Ant. tibial N.
Fig. 235.— Musculo-cutaneous nerve and anterior tibial nerve.
(After Hirschfekl, simplified.)
distributing itself over the upper part of the antero-external region of the
Terminal Branches
1. Anterior tibial nerve.-This nerve penetrates into the compartment
of the extensors, and descends at fust outside, then in front of, and later
internal to the anterior tibial artery, it then lies deeply m the muscular
interspace that separates the anterior tibial on the inner Side from the
236 NERVE WOUNDS
extensor communis, and later, from the extensor proprius hallucis on the
outer side.
At the level of the annular ligament of the ankle, the nerve passes
beneath the tendon of the extensor hallucis, appears on its external border
and splits up into its terminal branches.
The anterior tibial nerve supplies from its collateral branches :
1. The tibialis anticus by means of two branches, superior and
inferior.
2. The extensor communis digitorum pedis ;
3. The extensor proprius hallucis.
At its termination, it divides into two branches, external and internal.
The internal branch, more widely distributed, proceeds along the first
intermetatarsal space, covered by the extensor brevis digitorum, and
anastomoses in the most variable fashion, with the terminal branches of the
musculo-cutaneous.
The external branch is divided into several shoots which also proceed
along the second, third and fourth intermetatarsal spaces and anastomose
with the branches of the musculo-cutaneous.
It supplies the motor innervation of the extensor brevis digitorum.
The anterior tibial shares but feebly in the sensory innervation of the
dorsal surface of the foot. It mainly supplies articular and periosteal twigs ;
its branches of cutaneous sensibility, when they exist, are merged in the
branches of the musculo-cutaneous. Still, in certain cases, it is possible to
meet with a distinct sensory region for the anterior tibial occupying the
dorsal surface of the first metatarsal and of the great toe, and especially the
first inter-metatarsal space.
2. Musculo-cutaneous nerve. — The musculo-cutaneous separates at an
acute angle from the anterior tibial, amidst the fibres of origin of the
peroneus longus.
In passing through this muscle, it reaches obliquely the interspace
between the extensor communis on the inner side, the peroneus longus and
the peroneus brevis lying on the outer side.
It becomes superficial at about the lower third of the leg.
In its course the musculo-cutaneous supplies :
The peroneus longus and the peroneus brevis.
It supplies cutaneous twigs to the lower part of the antero-external
region of the leg.
It finally divides at the lower third of the leg into two terminal
branches.
1. The internal dorsal cutaneous nerve of the foot, which supplies the
internal collateral of the great toe.
The first dorsal interosseous nerve, which produces the external
collateral of the great toe and the internal collateral of the second toe.
The second dorsal interosseous nerve, which supplies the external
collateral of the second and the internal collateral of the third toe.
SCIATIC NERVE
237
2. The middle dorsal cutaneous nerve, which supplies only the dorsal
interosseous of the third interspace and its two collateral branches.
It must be noted that the fourth dorsal interosseous nerve comes from
the external saphenous (internal popliteal).
As in the hand, the dorsal collaterals do not reach the extremity of the
Exter. saph. N.'
Inner head of gastrocnemius
Int. pop. N.
Poster, tibial. N.
Great sciatic N.
Ext. pop. N.
Int. pop. N.
Outer head of gastrocnemius
to soleus
>N. to tibialis posticus
N. to long, flexor
r
N. to flexor longus hallucis
N. to tibialis posticus
N. to flexor longus
Post, tibial N.
Calcaneal branch
-xter. saph. N.
>-'
Fig. 236. — Internal popliteal nerve and posterior tibial nerve. (After Sappey.)
toes. The ungual phalanx is supplied by dorsal branches coming from
plantar collaterals.
II.— INTERNAL POPLITEAL NERVE AND POSTERIOR TIBIAL
NERVE
More bulky than the external popliteal, the internal popliteal nerve is
continued in the direction of the trunk of the sciatic.
It traverses the popliteal space and is given off in the angle formed by
the biceps and the semi-membranosus, passing downwards below into the
2 3 8
NERVE WOUNDS
space between the two heads of the gastrocnemius and passes under the
aponeurotic arch of the soleus. In this course it is in relation to the
popliteal vessels ; we then find from without inwards and from behind
forwards the nerve, the vein and the artery. The arch of the external
saphenous vein opens into the popliteal vein, crossing the posterior and
internal surface of the nerve.
Inter, pop. N.
N. to inner head of gastrocnemius
Exter. saph. N.
Inter, saph. N
Inter, saph. N. (post
. far.)-!
Exter. saph. N.
Inter, saph. N
Post, tibial. N. (calcaneal br.)
Exter. saph. N. (calcaneal br.)
Ext. pop. N.
Fib. cut.
N. to exter. head of gastrocnemius
N. to soleus
Ram. coram, fib.
Anastom. of exter. saph. and r.
coram, fib.
Fig. 237. — External saphenous nerve and ramus communicans iibularis.
(After Hirschfeld.)
Starting from the fibrous arch of the soleus, the internal popliteal takes
the name of posterior tibial.
The posterior tibial nerve descends between the superficial layer and
the deep layer of the posterior muscles of the leg. It lies in the cellular
interspaceseparating the tibialis posticus from the flexorcommunisdigitorum ;
it closely adheres to this deep muscular layer by means of the deep or
sub-solear aponeurosis ; it is covered by the soleus and afterwards by the
Achilles tendon.
The posterior tibial artery, originating in the popliteal trunk,
SCIATIC NERVE 239
crosses the anterior surface of the nerve and becomes internal. Thus the
nerve descends almost midway between the posterior tibial artery on the
inner side, and the peroneal artery on the outer side.
At the level of the instep, the nerve and the posterior tibial vessels
appear in the internal retro-malleolar groove ; the nerve is behind the
artery and internal to it, i.e. deeper and more closely adherent to the bone
covered by the tendon of the flexor longus.
It is in this retro-malleolar groove, at the entrance of the calcanean
groove which forms its continuation, that the posterior tibial nerve divides
into its two terminal branches, the internal and the external plantar nerves.
Collateral Branches
I. In the popliteal space, the internal popliteal supplies a certain
number of muscular branches :
1. The nerve to the inner head of gastrocnemius.
2. The nerve to the outer head of gastrocnemius.
3. The nerve to the soleus.
4. The nerve to the plantaris.
5. The nerve to the popliteus with muscular and vascular branches
and a branch to the interosseous membrane.
6. It also supplies articular branches grouped by Cruveilhier under the
name of posterior articular nerve of the knee.
7. Finally, it supplies an important sensory branch, the external
saphenous nerve or tibial saphenous which is given off at the upper or
middle part of the popliteal space, rejoins the external saphenous vein at
the upper part of the leg, and descends with it in the middle line, bein«;
covered by the superficial aponeurosis which ensheaths it in a fibrous
canal.
At the lower part of the leg, it appears on the outer side of the
Achilles tendon and at this level receives an important anastomosis from
the ramus communicans fibularis. It finally reaches the outer edge of the
foot, describing a curve round the outer malleolus.
The external saphenous nerve sends out no sensory twig to the upper
part of the leg.
It supplies cutaneous branches to the lower part of the leg, in the
malleolar region (external calcanean nerves) ; in front of the malleolus it
anastomoses with the musculo-cutaneous.
Near the tuberosity of the fifth metatarsal, it divides into two terminal
branches : the outer one becomes the external dorsal collateral of the fifth
toe ; the inner one, the nerve of the fourth interosseous space, supplies the
internal collateral of the fifth toe and the external collateral of the fourth
toe.
240
NERVE WOUNDS
2. At the level of the leg below the fibular arch of the soleus, the
posterior tibial nerve which continues the internal popliteal supplies :
The tibialis posticus ;
The flexor proprius hallucis ;
The flexor communis digitorum.
It also supplies vascular branches, articular branches for the tibiotarsal
Inter, plantar N.
Branch to accessorius
Br. to adductor hallucis
Br. to ilexor brevis
Ext. br
Int. bi
Br. to abd. minimi digiti
r. to accessorius
Ext. plantar N.
Ext. plantar N. (deep branch)
N. to add. min, dig.
I Collate
ral to toes
Superficial region.
Fig. 238. — Plantar nerves. (After Sappey.)
articulation and sensory branches of but slight importance : the internal
supra-malleolar branch and the internal calcaneal! nerve.
Terminal Branches
The two terminal branches, the internal and external plantar nerves,
reach the sole of the foot by the retro-caleanean groove and separate at an
acute angle, making their way towards the inner and outer sides of the foot.
They proceed between the two muscular layers of the sole of the toot ;
covered by the belly of the short flexors ; lying on the accessorius which
separates them from the interossei and on the tendons of the flexor
proprius hallucis and the flexor communis digitorum.
Their respective distribution somewhat resembles that of the median
and ulnar in the case of the hand.
1. Internal plantar nerve. — -Apart from its articular branches, the
internal plantar nerve supplies both muscular and cutaneous branches.
SCIATIC NERVE
241
The muscular branches destined for the muscles are :
Abductor hallucis ;
Flexor brevis hallucis ;
Flexor brevis digitorum pedis ;
Accessorius.
The cutaneous branches arc of two orders. Firstly, simple collateral
branches which perforate the plantar aponeurosis and supply the plantar
integuments from the os calcis to the base of the toes. These are the
plantar cutaneous nerves.
Int. plant. N
Ext. hi
Int. bi
N. to adduc. obliq.
N. to interossei
N. to abductor transversus
Ex. plant. N.
Superficial br.
Deep br.
N to adductor transversus
Deep dissection of the foot.
Fig. 239.— Plantar nerves. (After Sappey.)
Secondly, terminal branches, two in number :
The internal branch which supplies only the internal plantar
collateral of the great toe ;
The external branch which supplies the first, second and third
interdigital nerves and the plantar collaterals springing from them. The
third interdigital nerve receives from the external plantar nerve an
anastomosis analogous to that supplied by the ulnar to the median.
It is the plantar collaterals that supply, by means of their dorsal
branches, the dorsal surface of the ungual phalanges.
2. External plantar nerve. — The external plantar nerve also supplies
both muscular and cutaneous branches.
1. By its collateral muscular branches it supplies the abductor minimi
digiti pedis and the flexor brevis minimi digiti pedis.
Its deep terminal branch curves inwards and penetrates the deep
16
242
NERVE WOUNDS
compartment of the sole, then, like the deep branch of the ulnar, it
proceeds to supply all the plantar interossei, including the adductor
transversus and the adductor obliquus and all the dorsal interossei, by
means of its perforating branches.
2. On the other hand, the superficial terminal branch of the external
plantar is 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).
The plantar collaterals, through their dorsal branches, provide the dorsal
innervation of the ungual phalanx.
PARALYSIS OF THE SCIATIC
Before studying paralysis of the sciatic in its entirety, we will study
separately the paralyses of each terminal branch, the external popliteal and
the internal popliteal.
I— PARALYSIS OF THE EXTERNAL POPLITEAL
Motor Syndrome
The external popliteal supplies the muscles of the antero-external
compartment of the leg :
The tibialis anticus ;
The extensor longus digitorum pedis ;
The extensor proprius hallucis ;
The extensor brevis digitorum is supplied by the
anterior tibial ; the peroneus brevis and the peroneus
longus are supplied by the musculo-cutaneous.
Paralysis of this nerve is indicated by suppression of
the elevation and extension movements of the foot *
and of the toes, by the abolition of internal rotation
and of elevation of the internal border of the foot,
movements produced by the tibialis anticus ; by the
loss of external rotation, of abduction and of elevation of
the external border of the foot, movements produced
by the peroneal group.
To those main disturbances is added the collapse of
the arch of the foot normally maintained by the tendon
of the tibialis anticus and of the peroneus longus. The
Fig. 240. — Muscles tibialis posticus (internal popliteal) supports and raises
supplied by the . . r , , ,
external popliteal. on v tne inner portion or the plantar arch.
* Wc use the expression "extension of the foot " for the dorsal raising of the foot, comparing
it with the synergic movement of raising or extending the toes, and from analogy between the
functions of the extensor of hand and fingers, and the external popliteal.
By flexion of the foot we mean the movement of lowering the toes, analogous with flexion of
the hand.
SCIATIC NERVE
2 43
This paralysis results in a drooping of the foot with the toes pointing
towards the ground, and in a characteristic gait : steppage.
Fin. 241. — Paralysis of the external popliteal. Atrophy of the antero-external
group. Foot-drop, with dorsal tumour of the tarsus.
The toes are flexed from the loss of the antagonism of the extensors.
As Pitre and Testut have observed, we may easily detect the existence
of paralysis of the external popliteal
by asking the patient, who is seated,
to raise his toes and keep them
clear of the ground, the heel re-
maining on the ground.
Paralysis of the external popli-
teal is easy to recognise. Later
on we shall see what are the possible
errors in diagnosis.
Here we will mention only one
of these : the possibility of attri-
buting to the tibialis anticus the
slight power of adduction possessed
by the tibialis posticus, either volun-
tary or resulting from electrical
stimuli. To avoid this error, it is
sufficient to raise the foot and keep
it at right angles ; in this position
the smallest contractions of the
tibialis anticus are indicated both
by adduction and by raising the
foot ; there is distinctly perceived
beneath the skin the rising of the
tendon : adduction movements without raising the foot are produced by the
tibialis posticus.
242. — Steppage in paralysis of the
external popliteal.
244
NERVE WOUNDS
Sensory Syndrome
The complete sensory d
I
A
V
Figs. 243 and 244. — Sensory
distribution of the external
popliteal, comprising : the
peroneal cutaneous branch
(external surface of the leg) ;
the ramus communicans
fibularis (posterior surface) ;
the anterior tibial and the
musculo-cutaneous (dorsal
surface of the foot).
istribution of the external popliteal comprises a
broad tract occupying the entire antero-
external surface of the leg and a part of its
posterior surface ; it spreads over the dorsal
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.
The antero-external surface of the leg is
supplied by the peroneal cutaneous branch,
the posterior part by the ramus communicans
fibularis ; the musculo-cutaneous is distributed
only over the lower region of the leg and the
dorsal surface of the foot. To this latter
region are confined the sensory disturbances
observed when the lesion of the external
popliteal is below the first two branches ; this,
indeed, frequently happens, for the ramus
communicans fibularis and the peroneal
cutaneous branch have their origin rather
high in the upper region of the popliteal
space.
Moreover, we must not expect to find
complete anaesthesia ; it is not constant, and
when it exists is to be found only at the
middle of the external surface of the leg and
on the dorsal surface of the foot.
Trophic and Vaso-Motor Syndrome
Occasionally we find dorsal oedema of the foot, pallor or cyanosis of the
integuments ; cutaneous desquamation, hypertrichosis.
In some cases we have found traumatic ulcers on the back of the foot,
produced by the boot ; their extremely slow cicatrisation is a sign of
trophic disturbances.
Finally, if foot-drop is considerable and hypotonia prolonged, we may
observe a sort of tumour on the dorsum of the tarsus, comparable with the
dorsal tumour of the carpus in musculo-spiral paralysis.
As a rule, however, trophic and vaso-motor disturbances of the
external popliteal are of slight importance, the result of substitution by the
internal popliteal.
SCIATIC NERVE
245
I.— CLINICAL FORMS OF PARALYSIS OF THE EXTERNAL
POPLITEAL
As in the case of all nerve trunks, we may find the syndrome of
complete interruption or of simple compression.
The syndrome of com-
plete interruption is charac-
terised :
By complete and rapid
loss of muscular tone, intensi-
fying the foot-drop ;
By rapid muscular
atrophy ;
By the localisation of the
resulting formication to a
definite area ;
By permanence and fixity
of anaesthesia as well as by
the absence of paresthetic
zones.
In the syndrome of com-
pression we note the opposite
characteristics, particularly the
prolonged persistence of mus-
cular tone.
If nerve regeneration takes
place, we follow the pro-
gression of formication along
the paralysed nerves simul-
taneously with the reappear-
ance of muscular tone.
We may also meet with
syndromes of nerve irritation,
with cutaneous trophic dis-
turbances, tendon adhesions,
scaly desquamation, pain by
pressure on muscles and nerve
trunks, muscular fibrous con-
tractions which limit the
passive flexion of foot and toes
and consequently diminish
steppage.
Before the
operation.
The 95th day
after suture of
the nerve.
b
Fig. 245. — Attitude of the right foot when walking,
before and after nerve suture in a case of para-
lysis of the external popliteal with syndrome of
complete interruption in section of the nerve
by shell splinter (Captain C ). a. Muscular
atony and droop of foot and basal phalanges of
toes before nerve suture ; foot swinging, equino-
varus, dorsal swelling of the metatarsus. Photo-
graph taken on the 66th day after the wound.
/>. Return of tone showing attitude of the foot
on the 95th day after suture of the nerve; the
foot is no longer swinging, walking is easier,
running is possible, pes euuinus less pronounced,
the varus has almost disappeared ; the basal
phalanges are no longer drooping but extended
on the metatarsals ; dorsal swelling of the meta-
tarsus has disappeared. So far there is neither
elevation movement of foot nor extension move-
ment of the first phalanx of the toes, 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
the peroneals). (J. and A. Dejerine and Mouzon.
Presse Medicate, 10 May, 191 5.)
These neuritic, or even
simple neuralgic syndromes, however, are somewhat rare.
The external
246
NERVE WOUNDS
popliteal, like the musculo-spiral, and in contradistinction to the internal
popliteal, is not a very sensitive or painful nerve.
14th November, before
the operation.
a b
1 6th December, 20th day
after suture of nerve.
a b
2nd March, 97th day
after suture of nerve.
a b
A B C
Fig. 24.6. — 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 ).
Note in B the appearance of a small zone of paresthesia on the dorsal surface of the
first interosseous space. Black: pricking causes no sensation. Horizontal hatching:
pin-prick is felt simply as contact. Oblique hatching : diminished sensibility to touch
and pin-prick. Oblique hatching with points and crosses : hypo-sesthesia with inter-
mittent hyperesthesia ; the crosses indicate delayed persistent sensations, with diffusion,
irradiations and errors of identification, the points indicate that the sensation of pin-
prick is, in addition, particularly disagreeable (paresthesia). (J. and A. Dejerine and
Mouzon. Presse Medicate, 10 May, 19 15.)
Finally the external popliteal may be affected by dissociated lesions and
partial paralysis.
We will relate two instances of these.
Exter. pop.
Orifice of bullet.
Fig. 247.— Dissociated paralysis of the external
popliteal affecting solely the fibres of the
anterior tibial.
FlG. 248. — Sensory distribution of
the anterior fibres of the external
popliteal (same case as Fig. 247).
SCIATIC NERVE
247
In the first case a bullet had struck the anterior part of the external
popliteal, behind the head of the fibula. The muscular group of the
anterior tibial was paralysed ; the peroneal muscles were not affected.
The internal part of the distribution of the musculo-cutaneous was devoid
of sensation.
In another case, a small shell splinter, embedded in the external and
posterior part of the external popliteal, almost at the same level, caused
paralysis accompanied by nerve pains in the peroneal muscles alone,
together with hyperesthesia of the external part of the cutaneous dis-
tribution.
We may therefore conclude that, behind the head of the fibula, the
fibres destined for the anterior tibial are in front, the fibres of the peroneals
are behind. In the thigh, the fibres destined for the tibialis anticus form
the most external group of the external fasciculi of the sciatic nerve which
represent the external popliteal. This position corresponds to the very high
root origin of the nerve fibres to the tibialis anticus (fourth lumbar).
II.— PARALYSIS OF THE ANTERIOR TIBIAL NERVE
The anterior tibial nerve may be affected separately after bifurcation
of the external popliteal.
Its paralysis exactly reproduces the type of dissociated paralysis which
we have just been studying.
FlG. 2+9. — Paralysis of the anterior tibial nerve. Foot-drop with steppage. Integrity
of the musculo-cutaneous. Retention of lateral movements by the action oi the
peroneals. Faradic excitation of the external popliteal nerve causes only the projection
of the peroneal tendons, without raising- of the foot and the toes.
The extensors and the tibialis anticus are paralysed, whereas the
peroneals are untouched.
Cutaneous anesthesia is almost absent ; the anterior tibial is but
slightly sensory, it possesses no distinctive region of its own, for its
248
NERVE WOUNDS
cutaneous branches anastomose with the branches of the musculo-
cutaneous. Its terminal branches are more specially articular and
periosteal, comparable to the terminations of the posterior branch of
the musculo-spiral. At most there is slight hype-
resthesia of the dorsal surface of the foot, more
pronounced near the inner edge, and more especially
a small triangular region of anaesthesia behind the first
interdigital space.
The anterior tibial nerve may also be affected
below the branches destined for the tibialis anticus and
the extensor longus.
Here we have isolated paralysis of the extensor of
the great toe, which remains flaccid and half flexed,
whilst the other toes can easily be raised.
Finally, paralysis of the external popliteal and of
the anterior tibial is always accompanied by paralysis
of the extensor brevis digitorum muscle which is sup-
plied by the anterior tibial nerve ; it is recognised mainly
by flaccid ity of the muscle and disappearance of its
faradic contractions ; for after all the accessorius is but an
accessory synergic muscle of the extensors of the toes.
Fig. 250. — Sensory
distribution of the
anterior tibial.
Fig. 251. — Isolated paralysis of the extensor of the great toe, caused by lesion of the
anterior tibial at the middle of the leg. The patient can easily raise the other four
toes.
III.-ISOLATED PARALYSIS OF THE MUSCULO CUTANEOUS
Isolated lesion of the musculo-cutaneous nerve is shown by paralysis
of the peroneals, with loss of abduction, of rotation outwards and of eleva-
tion of the external edge of the foot.
Raising the foot is still possible by means of the extensors ami the tibialis
sciatic np:rve
249
anticus, but, since antagonism of the peroneals is lacking, they are accom-
panied by a rotation inwards, by adduction and elevation of the inner edge,
effected by the tibialis anticus. If there is considerable hypotonia of the
peroneals, paralytic talipes varus may result, and the patient walks on the
outer edge of the foot.
The musculo-cutaneous nerve is 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 musculo-
cutaneous, producing, on the left, a deviation
of the foot inwards (paralytic talipes varus).
Fig. 253. — Sensory dis-
tribution of the mus-
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
the first interspace specially supplied by the anterior tibial.
It 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,
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 ; one
particularly painful case even necessitated 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
Lesions of the internal popliteal produce paralysis of all the posterior
muscles of the leg and of all the plantar muscles.
There results disappearance of the 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 its inner
part (tibialis posticus) together with con-
siderable weakening of rotation and adduc-
tion movements, incompletely carried out
by the tibialis anticus.
Loss of adduction and abduction of the
toes (adductors and abductors of the first
and fifth toe, dorsal and plantar inter-
ossei).
Nevertheless, at first, walking does not
appear to be greatly impeded. Paralysis
of the internal popliteal may pass unnoticed
on a superficial examination.
All we see is that the patient puts his
foot flat down ; that he does not lift the
that he cannot rise
on his toes.
Fig. 254. Fig. 255.
Fig. 254. — Muscles supplied by
the internal popliteal. Super-
ficial layer, gastrocnemius, soleus,
plantaris.
Fig. 255. — Deep layer. Popliteus.
Tibialis posticus. Flexor longus heel from the ground
digitorum. Flexor proprius
hallucis. These last three mus-
cles are supplied by the posterior The patient, when seated, is unable to
tibial below the fibrous arch of ra ise his heel by using his toes as a fulcrum.
(Pitres and Testut.)
The internal plantar arch is flattened out, being deprived of the support
of the 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, and with a degree of uneasiness which
is 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.
the soleus.
SCIATIC NERVE
251
The toes are in simple extension or even in hyper-extension, according
as the tone of the flexors and interrossei persists or not.
When the patient attempts to raise and stretch his toes, we sometimes
find a curious attitude of extreme hyper-extension of the toes, caused by the
Fig. 256. — Paralysis of the internal popliteal. Hyper-extension of the toes by contrac-
tion of the extensors and loss of 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 sensory region comprises the entire plantar surface ; the back and
lower part of the leg vip to about the middle third ; the outer edge of the
foot and the outer part of its dorsal surface limited by a line which joins
the third interdigital space ; the dorsal surface of the last phalanx of
the toes.
If the trunk of the sciatic is injured below the origin of the external
saphenous, the external edge of the foot and the part close to its plantar
surface naturally retain their sensibility.
Trophic and Vaso-motor Syndrome
In simple paralysis, as the result of compression or complete inter-
ruption, trophic and vaso-motor disturbances are almost entirely absent.
It is seldom that we find cyanosis of the toes or pronounced cutaneous
disturbances; plantar hvper-hydrosis, however, is 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.
We have several times found superficial sores of this kind, caused by
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 ; they also affect the toe-
nails which are not touched by the external popliteal.
Fig. 257. Fig. 258. Fig. 259. Fig. 260.
Figs. 257, 258, 259, 260. — Sensory area of the internal popliteal comprising : the
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 we may say the same as for the
external ; trophic and especially vaso-motor disturbances are less pro-
nounced in isolated paralysis of this nerve than in complete paralysis of
the sciatic. Probably they are modified by substitution of the external
popliteal.
Clinical Types
We meet with both compression and interruption types in lesions of the
internal popliteal. Interruption types, moreover, are by far the more fre-
quent ; there is no need to insist on the characteristics by which they are
SCIATIC NERVE
253
to be recognised : early hypotonia and atrophy, fixity 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
neuralgic lesions capable of repro-
ducing all the syndromes of irritation
studied in the case of the upper limb.
The slight neuritic type, often
without complete paralysis, though
accompanied by pain on pressure on
the nerves and muscular bellies,
always causes slight fibrous contrac-
tion of the Achilles tendon gradu-
ally producing a certain degree of pes
equinus.
The grave neuritic types are
rather frequent, accompanied by in-
tolerable pains, suppressing sleep and
necessitating the use of morphine ;
pressure on the nerve trunks, and
especially on the muscles of the calf
and on the plantar muscles, causes
violent pains.
Trophic disturbances are very
Fig. 2^2. Fibrous contraction <>t the
call and pes equinus caused by slight
neuritic lesion of the internal popliteal
at the upper par) of the popliteal space.
marked. Along with scaly desquamation, fibrous infiltration ot the skin,
254 NERVE WOUNDS
and the claw-like curve of the nails, we find that grave deformities
supervene.
Fibrous contraction of the calf soon immobilises the foot in a state of
forced flexion, suppresses the 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, we did not hesitate to practise resection of the
lesion 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, is serious only because of
the very long time it takes to cure.
Neuralgia of the internal popliteal frequently assumes the type of
causalgia. Next to the median, this is the nerve most frequently affected.
In these cases, we find the same absence of paralysis ; trophic and vaso-
motor disturbances are still less pronounced ; but the pains are often
terrible. These are the special violent pains affecting the entire limb
SCIATIC NERVE 255
with a burning sensation, caused by the slightest cutaneous touch far more
than by deep pressure, above all, provoked by the most trifling emotions.
Partial lesions of the internal popliteal produce dissociated syndromes
which enable us to set up the following fascicular topography ; we find,
from within outwards, the external saphenous nerve, then the plantar
nerves, the nerve to the inner head of gastrocnemius ; then further out
are the fibres to the tibialis posticus, to the flexor longus digitorum pedis,
the calcanean branches and the superficial branch of the external plantar
nerve. (J. and A. Dcjerinc and Mouzon.)
II.— PARALYSIS OF THE POSTERIOR TIBIAL NERVE
From the fibrous arch of the soleus onwards the internal popliteal
assumes the name of posterior tibial. This nerve is very often affected by
traumatisms in the calf or perforating wounds in the leg, though paralysis
of the nerve is frequently overlooked. Indeed, the gastrocnemius and
the soleus, supplied by the internal
popliteal, have retained their move-
ments j the muscles of the deep
layer, tibialis posticus, flexor com-
munis digitorum pedis and flexor
■ proprius hallucis, which receive
their branches from the posterior
tibial at the upper part of the
, „ , . „-.. FlG. 264. — Anaesthesia caused by lesion ot
leg, are usually untouched. Thus, the posterior tibial .
all disturbances are practically re-
duced to paralysis of the plantar muscles and partial anaesthesia of the
sole of the foot. In all wounds of the leg, systematic inspection should
be made of the attitude of the foot and the electrical reactions of the
plantar muscles ; a simple faradic examination will generally reveal neg-
lected plantar paralysis.
The attitude of the foot is rather characteristic. First, it is a hollow
foot, since atrophy of the plantar muscles intensifies the concavity of the
plantar arch, which is supported by the tendons of the tibiales and the
peroneals.
Frequently too it is an atrophied foot, owing to the disappearance of
the thick mass of the plantar muscles ; in some cases, after a time we may
see atrophy of the foot, which appears to be smaller, thinner and shorter than
the normal foot.
The toes form a special kind of grifft ; the first phalanx is hyper-
extended on the metatarsus by the pull of the extensors and by the
inaction of the flexor interossei of the first phalanx ; the second and third
phalanges, on the other hand, are strongly flexed by traction of the flexor
longus digitorum.
The toes thus seem to be bent back upon themselves, forming a sort
256
NERVE WOUNDS
of Z, the pulp lying on the ball of the toes formed by the metatarso-
phalangeal articulations.
Fig. 265. — Atrophy of the plantar muscles caused
by lesion of the posterior tibial at the lower
part of the leg.
Fig. 266. — Pes cavuswith
hyper-extension of the
toes caused by lesion of
the posterior tibial.
Normal foot. Paralysed foot.
Figs. 267 and 268.— Attitude of the foot in paralysis of the posterior tibial. On the
right, left foot paralysed in characteristic attitude. Hyper-extension of the first
phalanx, hyper-flexion of the second and third phalanges; projection of the metatarso-
phalangeal articulations which constitute the anterior end of the arch. On the left^
compare the normal right foot of the same patient.
The adduction and abduction movements of the toes are suppressed
by paralysis of the interossei.
The posterior tibial nerve possesses the same trophic activities as the
internal popliteal.
sciatic nervp:
257
Its interruption results in the frequent appearance of plantar ulcers
caused by injuries from the boot ; superficial sores which often take a very
long time to heal. Its irritation brings out the same nerve disturbances,
particularly fibrous contraction of the plantar aponeurosis, with gr'iffe of
the toes and muscular sclerosis.
Like the internal popliteal, it may be the seat of violent causalgia and
of prolonged neuralgic pains.
III.— EXTERNAL SAPHENOUS NERVE
Of all the branches of the internal popliteal, the external saphenous
alone deserves special mention, for it may be affected in its superficial
course on the posterior surface of the calf.
Its interruption causes anaesthesia, limited
to the external retromalleolar region, to the
external half of the heel and to the outer
border of the foot. It is followed by the
usual phenomena of regeneration accom-
panied by unpleasant formications and cuta-
neous paresthesia which may cause pain along
the course of the nerve if anything is worn
on the foot.
On the other hand, irritation of the nerve
is often the cause of painful heel, along with
cutaneous hyper-aesthesia so painful at times
that the patient does not dare to set his heel
on the ground and walks with difficulty,
carrying the weight of his body on the
inner portion of the metatarso-phalangeal
articulations.
Fig. 269. — Sensory area "t
theexternal saphenous nerve.
Note that the anxsthesia
does not reach the extremity
of the last two toes.
IH._PARALYSIS OF THE SCIATIC TRUNK
Lesions of the great sciatic nerve simply combine paralysis of the
internal popliteal with that of the* external popliteal. Atrophy is complete.
Progress, however, is possible, with a steppage gait, but the foot, in an
absolutely swinging condition, is no more than an insensible inert appen-
dage supporting the weight of the body, thanks to the rigidity of the
lower limb, a rigidity maintained by the hamstring.
In these cases, there is considerable and often widely diffused atrophy
of the leg, the sensory, trophic and vaso-motor disturbances are more
pronounced, for collateral substitution is no longer possible.
To paralysis of the muscles of leg and foot may be added paralysis of
the posterior muscles of the thigh supplied by the collateral branches ot
the sciatic.
17
258
NERVE WOUNDS
These muscles receive their motor hranches at different and some-
what variable levels.
The semi-tendinosus, supplied wholly at the upper portion of the
thi^h, below the sciatic notch, is scarcely ever injured.
^The semi-membranosus and the long head of the biceps, supplied a
little below, are sometimes paralysed.
The short head of the biceps, the motor twig
of which is given off at the middle of the thigh,
is very often affected ; paralysis is indicated by
appreciable weakening of the biceps.
Fig. 270. — Lesion of the sciatic (complete
interruption at the level of the sciatic
notch). Wound 13 months old. Con-
siderable atrophy of all the muscles of
the leg. Paralysis of the posterior
muscles of the legs, except the semi-
tendinosus.
Fig. 271.- — Muscles sup-
plied by the trunk ot
the sciatic itself. On
the outer side is the
biceps, semi-tendinosus
and semi-membran-
osus.
Preservation of the semi-tendinosus suffices in all these cases to assure
persistence of flexion of the leg on the thigh, the abolition of which is
therefore exceptional.
The sciatic nerve, like its branches, may be interrupted, compressed
or irritated. Injuries of this nerve may produce all the paralytic, neuritic,
neuralgic and causalgic syndromes which we have already studied.
The neuritic types are extremely frequent, affecting either the whole
or only part of the nerve distribution. They arc indicated by the usual
SCIATIC NERVE
259
trophic disturbances, fibrous infiltration and desquamation of the skin,
profuse sweats or dryness of the integuments ; sclerosis of the dermis ;
muscular, tendon, and aponeurotic contractions. They may immediately
be recognised, simply by pressure on the calf or the sole of the foot, which
is extremely painful ; whilst almost invariably they culminate in fibrous
contraction of the calf, combined with pes equinus, and sometimes even
in fibrous griffe of the toes.
Fig. 272. — Complete interruption of the sciatic at the upper part of" the leg. Paralysis
of the biceps and of the semi-membranosus. The unaffected semi-tendinosus is
capable of producing considerable flexion of the leg on the thigh. Here its tendon
shows as a very obvious projection on the inner side of the popliteal space. Absence
of contraction of the biceps, the tendon of which is invisible on the surface.
It must be remarked that vaso-motor and trophic disturbances of the
neuritic types are usually more pronounced in lesions of the trunk of the
sciatic than in wounds of the internal popliteal or of the external popliteal,
doubtless because of the impossibility of substitution.
In some cases we find that simple contusion of the sciatic nerve gives
rise to persistent neuralgia, veritable traumatic sciatica, the cure of which
is a very long process. The nerve is painful under pressure at the level
of Valleix's points ; Lascgue's sign is almost always present, and we often
note slight hypertonia of the muscles of the calf, shown by a raising of the
heel, just as in common sciatica (Souques), suggesting true pes equinus.
Lastly, certain cases of slight neuritis of the sciatic produce the appear-
ance of actual contractions : contraction of the posterior muscles of the
leg and contractions of the calf, 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.
What particularly characterises the sciatic is, by reason of its bulk, the
frequency of partial lesions and of dissociated syndromes.
It must not be forgotten that bifurcation of the nerve takes place at
an extremely variable level, sometimes at the middle or even the upper
260
NERVE WOUNDS
part of the thigh. There are indeed cases in which the two branches of
the nerve issue from the sciatic notch separate, and pass on together, arranged
in gun-barrel fashion.
Fig. 273. — Severe neuritis of the sciatic nerve. (Edema of the foot, fibrous
infiltration of the dermis, cyanosis, cutaneous desquamation.
Even united in a single trunk, the fibres ot the internal popliteal and
of the external popliteal retain their relationship, being grouped together
at the internal and external part of the nerve.
Fig. 274. — Neuritis of the sciatic. Predominant cutaneous disturbances scaly skin
peeling off" in broad flakes (integrity of the distribution of the internal saphenous).
Trophic disturbances of the nails.
We may then observe the most varied dissociations and combinations
resulting from lesion of the sciatic. A few instances may be given.
In some cases we have complete paralysis of the internal popliteal or
SCIATIC NERVE
261
of the external popliteal, accompanied by simple weakening of the other
nerve.
In other cases, paralysis is complete in the nerve distribution of both
nerves, but whereas it remains unchanging in the region of one of the
nerves, we find, in the other, that a syndrome of progressive regeneration
appears. Even before the muscles show the slightest sign of improvement,
the sign of formication indicates this difference in evolution. We find,
for instance, at the level of the lesion, a definite area of formication, un-
changing and localised in the sole of the foot ; on the other hand, we see
Fig. 275. — Contraction of the calf with pes equinus, caused l>y slight irritation
of the sciatic at the upper part of the thigh.
advancing below the lesion a zone of induced formication which is localised
on the dorsal surface of the foot ; the conclusion we arrive at is that there
exists an insurmountable obstacle to the fibres of the internal popliteal,
whereas the fibres of the external popliteal nerve are in process ot
regeneration.
We may find the association of simple paralytic disturbances in the
region of one of the nerves, and of ncuritic or neuralgic irritation in
the region of the other. Still, it must be remembered, in such cases, that the
neuritic symptoms of the internal popliteal are always far more intense and
262 NERVE WOUNDS
obvious ; the signs of irritation of the external popliteal, always more
widely distributed, are not apparent at first ; they have to be sought for.
The frequency and diversity of these dissociated syndromes of the
sciatic are a matter of importance, for a precise diagnosis of the nature and
seat of the lesion will frequently enable us to carry out partial and con-
servative interventions, these being specially easy in the case of the
sciatic.
DIAGNOSIS OF PARALYSIS OF THE SCIATIC AND ITS
BRANCHES
The various forms of paralysis of the sciatic are easy to recognise.
The seat of the wound in the course of the nerve, the topography of
the paralysed muscles, their atrophy and faradic inexcitability enable us
to determine the existence of the lesion and to eliminate all the causes of
error, which we will now enumerate :
Hysterical paralysis, or rather the group of functional paralyses, con-
stitutes the chief difficulty in diagnosis.
They are frequent and extremely variable as to their cause. Some-
times we are dealing with genuine hysterical paralysis or simply with the
functional inertia of wounded muscles ; sometimes after the recovery of a
nerve lesion, the paralysis persists — this is a functional condition, the result
of prolonged disuse of the muscle. The incapacity results from the pain,
contracture or retraction of the antagonistic muscles.
In all cases, a simple electrical examination with the faradic current
will suffice to show the functional nature of the paralysis.
We may also easily recognise cases of incapacity caused by the partial
destruction of the muscles or by section of the tendons ; first, by the site
and character of the wound ; secondly, and above all, by electrical ex-
amination. The muscular fibres which have escaped the more or less
complete destruction of a muscle still retain some faradic contractility,
unless there exists an associated nerve lesion. The divided muscles also
contract, and the contraction, not transmitted to the tendon, may be
regarded as a definite sign that they have been cut.
Lastly, the contractures and the fibrous cicatricial scleroses of the
muscles, and in particular the almost constant contractions of the calf
resulting from a wound of the gastrocnemius, or of the tendo Achillis, or
of the os calcis, 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, and the muscles have retained their
faradic contractility, though this is often difficult to determine in retracted
or contracted muscles.
SCIATIC NERVE
263
Sometimes a diagnosis of the various organic paralyses of the lower
limb is a little, more difficult.
Frequently peripheral neuritis appears almost identical with complete
or dissociated paralysis of the sciatic. In addition to the typical forms of
polyneuritis, of which the diphtheritic is the most frequent, certain forms
of neuritis peculiar to war must be mentioned ; of these we have found
three groups : polyneuritis resulting from trench dysentery, polyneuritis
Fig. 276. — Complete hysterical paralysis of the right lower limb, following a superficial
perforating wound of the buttock. Slight muscular atrophy from prolonged inaction
(16 months), normal electrical reactions, normal reflexes. Complete anaesthesia <>t the
lower limb. The patient, incapable of using his right lower limb, hops along on his
left leg with the help of a stick, leaving his right leg to drag behind him.
from frost-bite, polyneuritis from asphyxiating gases, two instances of
which we have localised to the region of the external popliteal. The first
and third are generally painless, neuritis from frost-bite, on the other hand,
is very painful, being accompanied by trophic disturbances together with
contraction of the plantar aponeurosis and of the plantar muscles.
In all these cases, the disturbances are mostly bilateral and symmetrical,
though they may predominate on one side ; the electrical reactions are
264 NERVE WOUNDS
profoundly affected — though, as a rule, the tibialis anticus is more or less
untouched, just as the supinator longus is, in saturnine musculo-spiral
paralysis. Finally, the absence of a wound and the history of the case
are usually sufficient to determine the diagnosis.
Lesions of the sacral plexus often reproduce the picture of complete or
of dissociated paralysis of the sciatic ; when we come to study the lumbo-
sacral plexus, we shall set forth the special characteristics of these root
paralyses.
Lumbo-sacral hematomyelia, caused by lumbar commotio or simply
by shell explosion, may also cause errors in diagnosis, but the root dis-
tribution of the motor and sensory disturbances, the almost invariable
association of sphincteric disturbances, and, above all, the dissociation of
sensibility join with the history in clearing up the diagnosis.
We shall return to this point in diagnosing root paralysis, the main
difficulty of which lies in cases of hematomyelia.
Cortical paralysis, limited to the lower limb and following on wounds
of the cranium, may in certain cases be mistaken for paralysis of the
sciatic. These cortical monoplegias, which are flaccid and spasmodic in
succession, are characterised by the absence of peripheral signs, the integrity
of the muscles and their normal electrical reactions, exaggeration of the
reflexes, Babinski's sign and the combined flexion of thigh and trunk.
We are far more likely to mistake them for hysterical paralysis than for
paralysis of a peripheral nerve.
Lastly, ischaemic paralysis of the foot, resulting from too tight a
bandage or from arterial obliteration, may sometimes be very difficult to
diagnose, the more so as it is rather frequently associated with nerve
lesions.
As in paralysis of a neuritic type, we observe pains that are violent,
spasmodic and evoked by pressure ; there are seen marked disturbances of
electrical reactions and objective disturbances of sensibility. The absence
of the topography characteristic of peripheral nerve lesion, the frequent pre-
servation of an attempt at contraction, the considerable fall of temperature,
the cyanosis and fibrous infiltration of the foot, the suppression of arterial
pulsation, the segmentary distribution of muscular 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 paralysis of the
trunk of the sciatic or of the external popliteal. It is important to
minimise this, just as we minimise the wrist drop in musculo-spiral
paralysis, in order to diminish the incapacity of the patient, and especially
to avoid the stretching of the muscles of the antero-external group.
SCIATIC NERVE
265
This is easily effected either by surgical boots or shoes, or by the
application of spring contrivances; or, more simply still, by the traction,
on the front part of the foot, of a spring or elastic, fastened either to a
girdle or to a shoulder strap.
Types of apparatus
suppressing steppage
Fig. 277. (P. Marie
and H. Meige.)
Kir.. 278. (A. Leri.
It is really surprising to find that patients, supplied with these very
simple contrivances, can take moderately long walks without much
fatigue; in spite of their paralysis they complain of only a very slight
degree of incapacity.
CHAPTER XVI
SMALL SCIATIC NERVE
The small sciatic nerve has its origin in. the first, second, and third sacral
roots.
It issues from the pelvis, along with the great sciatic nerve and the
Gluteus max
Super, glut
Great sacrosciatic
ligament
Long, puden
Small sciatic
N. (per. br.)
- Gluteus mini-
mus
Tensor fasciae
femoris
Pyramidalis
" Great sciatic N.
Quadratus
femoris
Gluteus maxi-
mus
Small sciatic N. (glut. br.
Fig. 279. — Nerves or" the gluteal region. (After Hirschfeld, simplified.)
inferior gluteal nerve (sacral plexus). Moreover, the inferior gluteal nerve
and the small sciatic are often described as the two branches of one and the
same trunk.
The posterior cutaneous nerve descends, internal to the great sciatic,
between the biceps and the semi-tend inosus as far as the middle part of
the popliteal space, where it divides into its two terminal branches.
SMALL SCIATIC NERVE
267
Collateral Branches
Along its course, it sends out a series of collateral branc
The gluteal branches, two or three in number, which
lower edge of the gluteus maximus to be distributed over
the skin of the lower and outer part of the buttock ;
The perineal branches which are given off at the
same level and are distributed over the skin of perineum
and scrotum ;
The femoropopliteal branches which appear at variable
levels and are distributed, on the inner and the outer
side, over the skin of the posterior part of the thigh.
Terminal Branches
he :
turn round the
/
1. A superficial branch which descends right to the
middle of the calf, distributed to the integuments ;
2. A deep subaponeurotic branch which proceeds
along the external saphenous vein and anastomoses with
the external saphenous nerve, about the middle part of
the calf.
The posterior cutaneous nerve of the thigh is thus
wholly sensory.
Its destruction is indicated solely by anaesthesia of Fig. 280. — Sen
the posterior surface of the thigh and of the upper part s . ory (lismhu
r d rr 1 tion or tncsmal
of the calf. sciatic nerve.
.
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.
These roots unite near the iliac crest, at
the level of the outer edge of the psoas.
The nerve crosses obliquely the iliac
fossa, in the angle formed between the psoas
and the iliacus.
It passes under Poupart's ligament out-
side the vessels from which it is separated
by a portion of the psoas.
It is under Poupart's ligament that it
divides into its many terminal branches,
diverging in every direction across Scarpa's
triangle.
The course of the nerve trunk then is
very short ; this fact explains why paralyses
of this trunk are so few.
Collateral Branches
In its intra-pelvic course the anterior
crural supplies the iliacus and the psoas ; it
also supplies a branch to the femoral artery
and the nerve to the pectineus.
Fig. 281. — Anterior crural nerve ami obturator
nerve. (After Sappey.) 1. Anterior crural
nerve. 2, 3. Nerve to the ilio-psoas. 4. External
musculo-cutaneous nerve. 5, 6, 7. Internal mus-
culo-cutaneous nerve. 8. Branch to the femoral
artery. 9, 10, n. Nerve to the quadriceps.
12. Internal saphenous nerve with 13, its patellar
branch anil, 14, its tibial branch. 15. Obturator
nerve. 16. Branch to the adductor longus. 17. Branch to the adductor brevis.
18. Branch to the rectus femoris. 19. Branch to the adductor magnus. 20. Lumbo-
sacral trunk. 2i. First sacral root. 22. Abdomino-pelvic sympathetic. 23. External
cutaneous nerve.
ANTERIOR CRURAL NERVE
269
Terminal Branches.
The anterior crural expands into a considerable number of branches
which frequently originate in two common trunks and which we may,
with Sappey, reduce to four groups.
1. The external musculo-cutancous nerve supplies a single muscle, the
sartorius, by means of several twigs (short and long branches). It
supplies three cutaneous branches :
External cutaneous nerve
Middle cutaneous nerve-f
Mid. cut.
Twig to sartorius
Mill, cut,
Access, inter, saph.
Inter, musculo-cut. N.
Int. cut. N.
Int. saph. N.
Inter, saph. access N.
Patellar branch
(Inter, saphen.
ti ranch to leg J
Fig. 282. — Cutaneous branches of the anterior crural. (After Sappey.)
The upper cutaneous perforating branch (middle cutaneous) which
passes through the sartorius and is distributed over the antero-external
part of the thigh internal to the external cutaneous nerve with which it
anastomoses ;
The lower cutaneous perforating branch (middle cutaneous) which
descends along the sartorius and perforates it at about its middle third, to
be distributed in the supra-patellar region ;
The accessory branch of the internal saphenous, one branch of which
270
NERVE WOUNDS
Br. perf,
Inter, saph. vein ■■
Inter, saph. ace.
Inter, saph. N. (patellar br.)
Inter, saph. N. (tibial br
remains close to the internal saphenous vein, and the other the deeper one,
follows the femoral artery ; both become superficial at the lower and inner
part of the thigh and supply the inner side of the knee.
2. The internal branch whose muscular branches pass behind the
femoral vessels and are distributed to the pectineus and to the adductor
longus.
The cutaneous branches
which pass in front of the
vessels are distributed over
the upper and inner part
of the thigh and anastomose
with the cutaneous branches
of the obturator.
3. The nerve to the
quadriceps from which origi-
nate :
The branch to the rectus
femoris ;
The branch to the vastus
externus ;
The branch to the vastus
internus ;
The branch to the crureus.
4. The internal saphe-
nous nerve rejoins the femoral
artery and descends into the
sheath of the femoral vessels
in front of the artery which
it crosses obliquely so as to
lie internal to it.
At the lower part of the
thigh, near the opening in
the adductor magnus, it leaves
the vessels, perforates the
anterior wall of Hunter's
canal and proceeds along the
inner side of the knee.
Becoming subcutaneous
at the level of the internal tuberosity of the tibia, it lies along the internal
saphenous vein which its main terminal (tibial) branch accompanies right
to the inner side of the foot.
Its collateral branches, of but slight importance, are :
The femoral cutaneous branch ;
The tibial cutaneous branch ;
The internal articular branch to the knee.
Inter, saph. vein —
Post. tib. N. (calc. br.)...
Musculo-cutaneous N.
Inter, saph. N.
Inter, saph. V.
Fig. 283. — Internal saphenous nerve.
(After Hirschfeld.)
ANTERIOR CRURAL NERVE
271
It has two terminal branches :
The patellar or anterior branch, which breaks away at the inner side of
the knee and supplies the supero-internal part of the leg.
The tibial or lower branch, which proceeds along the internal saphenous
vein and accompanies it throughout its entire course, supplying branches
to the whole inner surface of the leg.
Its posterior branch is distributed over the internal malleolar region.
Its anterior branch passes in front of the malleolus and is distributed on
the inner side of the foot as far as the base of the first metatarsal.
PARALYSIS OF THE ANTERIOR CRURAL NERVE
Paralysis of the anterior crural nerve is comparatively rare. This nerve
has quite a short course which corresponds solely
to the point at which it crosses the pelvis, where ff
it is protected by the pelvic girdle. Immediately
under Poupart's ligament it opens out into its
terminal branches and if the nerve is injured, in
Scarpa's triangle, only some of its terminal branches
are affected.
Paralysis of this nerve, therefore, is generally the
result of pelvic injuries.
Injury to the anterior crural nerve is shown solely
by paralysis of the pectineus, of the sartorius and of
the quadriceps, accompanied by loss of extension of
the leg on the thigh.
Atrophy of the crureus, absence of its power of
extension, loss of its normal electrical reactions and
abolition of the patellar reflex are so many signs
that enable us to recognise paralysis of this nerve.
As a rule, the patient can walk, but he does so
with his leg stiffened by contraction of the tensor
fasciae femoris, and the gracilis, for the lower limb,
thus maintained in a kind of hyper-extension, easily
bears the weight of the body ; but if the slightest
flexion takes place, the crureus muscle ceases to func-
tion and the patient sinks down on to his suddenly
flexed knee. He has also a special way of walk-
ing; advancing the healthy limb, he brings up the
paralysed one, plants it on the ground in hyper-
extension, maintained by contraction of the tensor
fasciae femoris and of the gracilis, and, on this un- |. |( . , s —Musclea
stable support, again begins to advance the healthy supplied by tin- an
Jj m k tenor crural : sar-
* tonus, pectineus,
As in fracture of the patella, walking backwards is quadriceps.
272
NERVE WOUNDS
as easy as walking forwards is difficult, for in this case the knee remains
in a state of permanent hyper-extension.
A frequent cause of error must be mentioned in summing up anterior
crural paralysis. We sometimes imagine that voluntary muscular con-
tractions persist just as we may observe electrical pseudo-contractions
of the paralysed crural triceps. This error originates in the voluntary or
electrical contraction of the tensor fasciae femoris (superior gluteal nerve),
Figs. 285 and 286. — Paralysis of the right anterior crural nerve by intra-pelvic lesion,
above Poupart's ligament ; slight consecutive hydrarthrosis of the right knee.
which thrusts inwards the triceps and imparts to it a transverse pull by
means of its aponeurotic slip.
It must not be forgotten that paralysis of the anterior crural is often
accompanied by hydrarthrosis of the knee, probably caused partly by the
slight and oft-repeated injuries which this articulation now has to sustain
and partly by the hyper-extension necessary for walking.
Disturbances of sensibility are localised on the anterior surface of the
thigh and on the inner surface of the leg.
A special study must be made of these latter disturbances and of
lesions of the internal saphenous.
LESIONS OF THE INTERNAL SAPHENOUS NERVE.
Of all the branches of the anterior crural nerve, the internal saphenous
is the only one the lesion of which is of special interest, since lesion of
ANTERIOR CRURAL NERVE
273
the other terminal branches causes no more than partial paralysis of the
sartorius and the crural triceps.
The long course of the internal saphenous exposes it to frequent lesions
capable of producing the various syndromes of simple anaesthesia, neuralgia
from nerve irritation, or even actual causalgia.
Its distribution covers the entire inner surface of the leg and spreads
upwards on to the antero-internal surface of the knee. It extends over
III
4
1 li
Anterior surface. Posterior surface. Inner surface.
Fig. 287. Fig. 288. Fig. 289.
Figs. 287 and 288. — Sensory region of the anterior crural. Above the knee, region
of the anterior crural proper. Below the knee, region of the internal saphenous.
Fig. 2S9. — Sensory disturbances in complete interruption ot the internal saphenous
nerve in Scarpa's triangle.
the internal malleolar region and over the inner side of the foot, to
end near the first metatarsal.
It is often somewhat enlarged in its upper part by simultaneous lesion
of the branch accessory to the internal saphenous, which follows in the
thigh the same course as the internal saphenous and is also affected as
a rule.
Neuralgia of the internal saphenous is at times so violent as to cause
considerable inconvenience in walking.
DIAGNOSIS
The diagnosis of paralysis of the anterior crural must be made from
functional paralysis and from reflex muscular atrophies which generally
18
274 NERVE WOUNDS
follow fractures of the femur and particularly lesions of the knee
joint.
Particular care must be taken in dealing with lesions of the lumbar
roots or with lumbar hematomyelias, which we will study along with the
syndromes of the lumbo-sacral plexus.
CHAPTER XVIII
OBTURATOR NERVE
The obturator nerve originates in the lumbar plexus from the second,
third, and fourth lumbar roots.
It appears internal to the psoas, passes
behind the common iliac vessels and pro-
ceeds along the brim of the inlet right
to the subpubic groove, covered by the
parietal peritoneum.
Superficial layer.
Deep layer.
Fig. 292.
Fig. 290. Fig. 291.
Fig. 290.— Anterior crural nerve and obturator nerve. (After Sappey.) 1. Anterior
crural nerve. 2, 3. Nerve to the ilio-psoas. 4. External branch of anterior crural
nerve. 5, 6, 7. Internal branch of anterior crural. 8. Branch to tin- femoral artery.
9, 10, ti. Nerve to the quadriceps. 12. Internal saphenous nerve, with .3- its
patellar branch and i+, its tibial branch. 15. Obturator nerve. 16. Branch .0 the
adductor longus. 17. Branch to the adductor brevis. 18. Branch to the gracilis.
19. Branch to the adductor raagnuB. 20. Lumbo-sacral cord. zi. 1' irst sacral toot.
22. Abdomino.pelvic sympathetic. 23. External cutaneous nerve.
FlGS. 2 9 ! and 292.— Muscles supplied by the obturator nerve. Superficial aver 1 ;.,Muc o,
longus, adductor magnus, gracilis. Deep layer , the sartonus, t he crural triceps and the
pectineus (crural nerve) hav, been removed, and the adductor longus (obturator nerve
has been cut to show the obturator externusand the adductor brevis, as well as the
lower part of the adductor magnus and of the gracilis.
276
NERVE WOUNDS
On leaving the obturator foramen or even in the subpubic groove it
divides into its terminal branches.
Branches
In its pelvic course it supplies chiefly the branch to the obturator
internus.
There are two terminal branches —
1. Superficial branch, which passes
in front of the adductor brevis and then
winds below the adductor longus.
It supplies at this level :
The branch to the gracilis ;
The branch to the adductor brevis ;
The branch to the adductor longus ;
A cutaneous branch which is distri-
buted over the supero-internal surface
of the thigh and anastomoses with the
internal saphenous.
2. Deep branch. — This, on the other
hand, passes behind the adductor brevis
and supplies the adductor magnus on
which it rests.
The obturator nerve is essentially
the nerve of adduction of the thigh. Its
secondary function is to rotate outwards
and to flex the thigh on the pelvis.
As a rule, adduction is not com-
pletely paralysed in lesions of the
obturator nerve, for the adductor longus receives secondarv innervation
from the anterior crural ; the adductor magnus also receives some twigs
from the sciatic.
Sensory disturbances appear in a triangular area occupying the inner
surface of the thigh.
Lesions of the obturator are even more rare than those of the anterior
crural ; like the latter it has a somewhat short trunk, also very effective
protection is afforded it by the bones and muscles of the pelvic girdle.
Figs. 293 and 294. — Sensory region
of the obturator.
CHAPTER XIX
EXTERNAL CUTANEOUS NERVE OF THIGH
The external cutaneous nerve originates in the second and third lumbar
roots.
branch. 15. Its'gcnital branch. 16, 17, 17'. The trunk, gluteal ami femoral branches
of the external cutaneous. 18. Genital branch, and 19, 19', crural branch <>t the
genito-crural. 20, 20'. Anterior crural nerve. 21,21'. Obturator nerve.
It emerges from the outer edge of the psoas, crosses the iliac crest, and
278
NERVE WOUNDS
IV
goes on its way lying on the inner surface of the pelvis a little below the
iliac crest, pressed against the iliacus by the parietal layer of the peritoneum.
, It issues from the pelvis through the
Lj' / i notch between the antero-superior iliac
spine and the antero-inferior iliac spine.
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.
Anaesthesia of this nerve covers a
region corresponding to the outer part
of the thigh ; its irritation, which is
rather frequent, causes the appearance
of a somewhat special neuralgia covering
the entire outer surface of the thigh,
rendering painful the contraction of the
extensor fasciae femoris, and known ever
since the description given of it by
W. Roth (1895) under the name of
neuralgia paraesthetica.
Several cases have been mentioned of
lesion of the external-cutaneous accom-
panied by painful irritation of the causalgic type.
Figs. 296 and 297. — Sensory region
oi the external cutaneous.
CHAPTER XX
GENITO-CRURAL NERVE
\
U
The genito-crural nerve originates almost exclusively in the second
lumbar root.
It makes its way forwards across the fibres of the psoas, emerges on
the anterior surface of this muscle, and descends, ,
parallel to this latter, right to the antero-inferior
iliac spine, below which it passes under Poupart's
ligament. It divides into two terminal branches :
1. The external or crural branch passes under
Poupart's ligament outside of the iliac vessels to
which it is applied, separated consequently from the
anterior crural nerve by the tendon of the psoas.
It 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.
There it supplies a small sensory region, oval
in form, covering almost the whole of Scarpa's
triangle.
2. The internal or genital branch breaks away
from the former before passing under Poupart's
ligament ; it bends back inwards to reach the
inguinal canal through which it passes together with
the vas deferens.
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.
Lesions of the genito-crural nerve are very v
& } riG.298. — Sensory region
rare; they show themselves, for the most part, in of the genito-crural.
sensory disturbances. We have met with lesions
that irritate the nerve, in the course of wounds of the abdominal wall,
manifesting themselves by painful hyper-aesthesia at the root of the thigh
and in the scrotum.
CHAPTER XXI
ILIO-HYPOGASTRIC NERVE
u /^
V
The ilio-hypogastric continues the first lumbar root and makes its way
obliquely towards the iliac crest, passing along its upper border, lying
between the internal oblique and the transversalis abdominis.
i. It gives off along its course a perforating branch which appears
above the gluteus maximus and supplies
the outer and upper part of the
buttock.
2. It supplies a musculo-cutaneous
branch or abdominal branch which gives
some motor twigs to the internal oblique
and to the transversalis, and is distri-
buted, by way of a perforating branch,
over the skin of the lower part of the
abdomen.
3. The third — genital — branch pro-
ceeds along the upper surface of Poupart's
ligament, lying in the depth of the
abdominal wall, between the transversalis
and the internal oblique.
It thus enters the inguinal canal and
emerges to spread out at the external
inguinal ring into branches which are distributed over the supero-internal
part of the thigh.
Figs. 299 and 300. — Sensory region
of the ilio-hypogastric.
ILIOINGUINAL
The ilio-inguinal appears as a collateral trunk of the ilio-hypogastric.
It originates in the first lumbar, proceeds like the latter along its lower
border, supplies a few muscular branches to the internal oblique and the
transversalis, and joins the ilio-hypogastric before leaving the inguinal
canal.
The ilio-hypogastric and ilio-inguinal * together really act as a true
intercostal nerve : their oblique course in the depth of the abdominal
* The description of these two nerves differs in some particulars from that current in English
Text-books. — (Ed.)
ILIOHYPOGASTRIC NERVE 281
wall, the motor branches supplied to the muscles of the abdomen, the two
lateral perforating cutaneous branches, and their terminal branch issuing
from the inguinal canal, represent the three perforating brandies of the
intercostal nerves.
Their sensory region consists, as does that of the intercostals, 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. The result of this is a sinuous tract corresponding to
the similar sinuosities of the twelfth intercostal nerve.
CHAPTER XXII
LUMBO-SACRAL PLEXUS
From the lumbo-sacral plexus all the nerves of the lower limb originate.
It consists of two distinct parts: the lumbar plexus, formed by the first
four roots ; the sacral plexus, consisting of the fifth lumbar root, and the
first, second and third sacral.
XII D
I L
Iliohypogastric and ilio-inguina
External cutaneous
Anterior crural
IV L
VL
Obturator
Lumbo-sacral cord
Fig. 301. — Lumbar plexus.
All the roots of these plexuses are united to one another by vertical
anastomoses, which form actual nerve loops from which the trunks that
constitute the peripheral nerves are given off.
LUMBOSACRAL PLEXUS
2«3
LUMBAR PLEXUS
A very simple description of the common types of lumbar plexus may
be given.
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.
The second lumbar root supplies the external cutaneous and thegenito-
crural, with the aid of the anastomotic loop originating in the first lumbar.
Ganglions of the
sympathetic
Fig. 302. — Connections between the lumbar plexus and its branches,
The anterior crural nerve is for the most part formed of the fibres
originating in the third lumbar, but it also receives an important contri-
bution from the second lumbar and even a more important one from the
fourth lumbar.
It is the fourth lumbar that supplies the obturator which also receives
fibres from the third and even from the second lumbar.
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,
the upper root of the sacral plexus.
The lumbar plexus is covered, on the sides of the vertebral column,
by the belly of the psoas muscle.
Through the fasciculi of this muscle emerge the different nerves formed
by the plexus ; the ilio-hypogastric and ilio-inguinal above and the
Ext. cutan. nerve — -Jp?.
Genito-crural N
5th lumbar ganglion
Obturator N.
Sup. glut. N.
N. to obtur. int. -!
Lumbo-sacral
cord
1 st sacral N.
2nd sacral N.
N. to levator ani
Pudic nerve
Inf. hemorr. N.
N. dors, penis
Sup. perineal N.
Dorsal N. penis
N. to trans, perinei
Long pudendal N.
Small sciatic N.
Fig. 303. — Sacral plexus. (After Hirschfeld.) Collateral branches.
anterior crural below appear on its external border, the external-cutaneous
on its anterior surface, the genito-crural and the obturator on its internal
border.
The collateral branches of the plexus are of slight importance ; they
are the branches supplied to the quadratus lumborum and to the psoas by
the first two lumbar roots.
SACRAL PLEXUS
The sacral plexus consists essentially of the fusion of the lumbo-sacral
cord (fifth lumbar and an anastomotic branch of the fourth lumbar) and
LUMBO-SACRAL PLEXUS
285
of the first three sacral roots, in one bulky trunk : the great sciatic
nerve.
It supplies several important collateral branches :
I. The superior gluteal nerve, which originates in the lumbo-sacral
cord and the first sacral, issues through the great sciatic notch, passes above
the pyramidalis, and proceeds between the gluteus minimus and the
gluteus medius, divides into an ascending branch and a descending branch
which penetrates into the tensor fascia femoris. It supplies the gluteus
minimus, the gluteus medius and the tensor fascia? femoris ;
Obturator
Superior gluteal
Pyramidalis
Superior gemellus
Inferior gemellus
Quatlratus femoris
Small sciatic N.
Lumbo-sacral cord r —
* /4('A '•• Levator &*"**
/!•'!''', \\ ani '*;-- Sacro-coccygeal ple>
;,' V|\obt. inter. ««^_.
\\ - > Int. Hemor. -a.-sthesia.
On the right, a region
resembl/ng the distribu-
tion of the lower lumbar
and the sacral roots. On
the left, a region resem-
bling the distribution of
the first and second lum-
bar, and of the fifth lum-
bar, the first and second
sacral. Dissociation of
sensibility. Thermal and
painful anaesthesia. Rela-
tive conservation ot tac-
tile sensibility ; almost
complete integrity ot
sensibility to pressure and
of the other deep sensi-
bilities.
296 NERVE WOUNDS
generally far more favourable than that of root lesions. In a few months,
even sometimes in a few weeks, we see a progressive diminution of the
region of paralysis and anaesthesia.
Improvement often passes on to complete cure, but anaesthesia may
persist, or even more commonly, well-defined paralysis.
PART IV
CONCLUSIONS
CHAPTER XXIV
PROGNOSIS AND TREAMENT OF PERIPHERAL
NERVE LESIONS
At the present time, basing our opinion on a very large number of
observations made since the beginning of the war, we are justified in
affirming that the prognosis of peripheral nerve lesions is on the whole
favourable.
Every peripheral nerve affected by traumatism tends to regenerate,
provided the general condition of the patient enables him to contribute
towards this restoration. It is this wonderful aptitude of the nerves
towards regeneration by fresh shoots from the axis-cylinders, that explains
the considerable number of spontaneous cures.
Surgical intervention itself has no other aim than to favour this natural
regeneration, by suppressing the obstacle to the progress of the nerve
fibres and bringing about coaptation of the segments of the divided
nerve, i.e. of the central segment containing the nerve fibres along with
the peripheral segment, the empty sheaths of which are alone capable of
guiding the axis-cylinders in their regeneration.
The wide-spread destruction of the peripheral nerves is also reparable
by nerve grafting which reconstructs the anatomical continuity of the
supporting tissues, the conductor of the regenerating fibres.
According to our personal statistics, we may estimate at between sixty
and seventy per cent, approximately the number of spontaneous regenera-
tions without surgical intervention ; at the same time, there are a certain
number of these, between ten and twenty per cent., which in our opinion
would have gained by such intervention ; a simple liberation or even a
nerve suture, if performed at the right time, would in all probability have
permitted of a more rapid and complete restoration.
We are now speaking of cases in which the neurological examination,
made only from eight to ten months after the wound, shows a nerve
manifestly to be on the way to recovery, though this may be slow and
298 NERVE WOUNDS
incomplete ; 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. After all, such cases should
become exceptional if the neurological examination is always made in
good time.
Consequently those cases of nerve lesion that necessitate surgical
intervention, whether liberation or suture, do not appear to be more than
thirty or forty per cent.
Results naturally vary according to the intervention practised. Still,
we may lay it down as a general principle that the liberation of a nerve,
when this is indicated, should always be successful ; if such is not the
case, it is because resection and suture were necessary, and intervention
should be resumed.
The results of nerve suture have been very much questioned ; to us,
however, there does not appear to be any doubt at all on the matter.
Nerve suture practised under favourable conditions almost invariably
succeeds. Out of one hundred and eight cases of nerve suture or grafting
which we have been able to follow up, there are only fourteen failures ;
i.e. 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, 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,
approximately (12*9 per cent, in our statistics) the cases of failure after
nerve suture.
We must add that the statistics here given do not deal solely, as one
might think, with only favourable cases, operated on at the right time and
under favourable conditions, but with all the cases we have investigated.
Early intervention does not appear to be an indispensable condition ;
we have witnessed the success of nerve sutures practised thirteen and
fifteen months after the wound ; it is quite possible that suture might
successfully be attempted long after this period. Nevertheless, there can
be no doubt but that early sutures are followed by more rapid regeneration.
A favourable prognosis for peripheral nerve lesions is, as we see, con-
firmed by these figures. More than half the patients are cured spon-
taneously ; almost all surgical interventions are attended with success.
The number of irreparable nerve wounds would certainly appear not
to exceed from eight to ten per cent. ; either because surgical intervention
has encountered insuperable difficulties or because the general condition
* Most of these cases were operated on at Le Mans by M. Delageniere, whom we take this
opportunity of thanking for his valuable advice.
TREATMENT OF PERIPHERAL NERVE LESIONS 299
of the patients has either annulled or made difficult the work of regenera-
tion. Amongst the factors contributing to failure, mention must be made
of alcoholism ; two cases of nerve suture carried out under the best of
conditions were succeeded by no sign of regeneration whatsoever in
patients manifestly alcoholic.
The figures we have cited, more particularly the proportion of successes
registered after nerve suture, may perhaps seem surprising. Tbey are
nevertheless correct, and may be compared with those of other neurological
centres, particularly that of Professor Dejerine at the Salpetrierc.
If they appear to clash with other published statistics, we affim that
this is because people are always too precipitate in speaking of the failure
of surgical intervention. It must not be forgotten that the regeneration
of a nerve is invariably an extremely prolonged task. Under the most
favourable conditions, and in the case of young patients, the progress of
the axis-cylinders is not more than one to two millimetres per day ; the
appearance of the first voluntary movements also takes place long after the
penetration of the axis-cylinders into the paralysed muscle. Consequently,
to affirm, three, four, or six months after nerve suture, the failure of inter-
vention because no movement shows itself, is a serious error, to be attri-
buted to nothing else than impatience on the part either of the observer
or of the patient ; besides, motor restoration is invariably the most tardy
of all.
We shall realise much more correctly the progress made if we try, on
the contrary, to discover the sensory signs of regeneration ; the sensibility
of the nerve to pressure and its characteristic formication, the sensibility
of muscular bellies, cutaneous paresthesia, etc.
The sign of formication is here specially important, since it enables us,
after a few weeks, to note the appearance of the axis-cylinders beyond the
suture, and to follow their progressive advance in the peripheral trunk.
It permits not only the observer but also the patient to follow the work of
restoration step by step ; it proves to him the success of surgical inter-
vention, gives him confidence and patience, and thus becomes an important
moral factor in the cure.
CHAPTER XXV
SURGICAL TREATMENT
I.— INDICATIONS FOR OPERATION
To lay down the indications for operation is assuredly the most delicate
problem in war neurology.
Apart from a few special cases, it would appear as though we ought
to reject the principle of prompt and systematic intervention for every
wound of the peripheral nerves.
Indeed, we have seen that the majority of nerve lesions, about sixty
or seventy per cent., were susceptible of spontaneous regeneration ; even
the diagnosis of complete interruption of a nerve trunk does not inevitably
imply the necessity of intervention, for even in these cases spontaneous
regeneration is often possible.
The only fact which necessarily calls for intervention is the absence
of regeneration of the peripheral segment, or else the defective, difficult
or partial character of the regeneration.
Consequently, before deciding to operate, we must make absolutely
certain, by successive examinations, that regeneration is either not taking
place at all or is progressing badly. It is scarcely ever possible to obtain
such certainty in less than two, three or even four months after the wound.
Besides, as we have already seen, this delay as a rule is in no way
prejudicial to the success of intervention.
Manifestly this recommendation must not be accepted as absolute ;
there are cases in which prompt operation is necessary, especially in simple
compression and severe neuritis.
I. -TIME OF INTERVENTION
We discovered that two or three months at least were often necessary
to establish the necessity of intervention.
On the other hand, an operation must be carried out as soon as
possible, once its necessity has been recognised.
Regeneration is assuredly more rapid and easy when the operation is
not delayed too long.
Still, it must not be forgotten that, even twelve or fifteen months after
nerve interruption, suture may be performed successfully.
SURGICAL TREATMENT 301
II.— CHOICE OF INTERVENTION
As clinical reasons alone can indicate the necessity of intervention, so
it is mainly by a clinical examination that the nature of the intervention
will be decided.
No intervention must take place until we have obtained every item of
clinical information to prove the existence of complete interruption or
simple compression, of a total lesion or a partial change, of regeneration
that is non-existent or is simply difficult to effect.
Assuredly this clinical information will not always suffice in deciding
upon a suture or a liberation ; account must naturally be taken of the
lesions encountered during intervention as well as of operative possi-
bilities ; though clinical reasons above all others are the most important.
A thorough preliminary examination, or rather a series of minute examina-
tions, almost invariably enable one to decide upon the kind of intervention
necessary.
Moreover, information given by the anatomical state of the nerve is
often somewhat difficult to interpret.
Evidently no hesitation will be felt in the presence of a complete
section, of a particularly dense nerve cicatrix or of bulky neuromata.
It must always be remembered that all neuromatous formations imply
the existence of an obstacle, above which the regenerated fibres, unable to
reach the peripheral segment, shrivel up. It is therefore always necessary
to remove the obstacle by liberation if it is external to the nerve and by
resection if it is interstitial.
In many cases, however, less clearly characterised, anatomical examina-
tion of the nerve is not sufficient to solve the problem.
Indeed, it is a matter of absolute importance to find out if there is
simple extrinsic compression or an interstitial obstacle ; if the lesion has
destroyed the continuity of the nerve fibres or has changed them locally ;
if the obstacle is permeable or not to the regenerating nerve fibres. This
information cannot be supplied by anything but a clinical examination.
In this connection, however, the electrical and histological examina-
tion of the nerve, exposed during the operation, has been recommended.
Direct electrical examination of the nerve trunk has been carried out
by P. Marie, H. Meige, and Gosset by using a small sterilisable metallic
electrode* which allows of separate excitation of the different fasciculi of
the nerve above and below the lesion. We may thus ascertain if these
fasciculi have remained excitable.
Evidently this method is capable of affording very important informa-
tion, though of itself alone it is insufficient. It proves very clearly that
certain fasciculi, or even the entire nerve, have not been touched by the
* Pierre Marie, Bull. Jc VAcad, de Med., meeting of 9 February, 191 5.
302 NERVE WOUNDS
lesion ; in addition, it has undoubted value by reason of the positive
information it gives. The negative information, however, has not the
same value ; electrical stimulation of the nerve shows no reaction what-
soever 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, because a nerve or a nerve fasciculus is incapable of being
excited, that it is not in course of spontaneous regeneration ; electrical
excitability of the nerve is, as we know, one of the most tardy signs of
regeneration ; the sensibility of the nerve to pressure, formication, the
return of tone, the appearance of paresthesia are earlier signs. Thus, by
taking account only of electrical inexcitability, we should run the risk of
resecting and suturing healthy sensory fasciculi and motor fasciculi, well
advanced in regeneration.
Histological examination of the nerve, by an actual operative biopsis,
has been recommended by A. Sicard.* This method consists in removing
a few particles of nerve tissue from the peripheral segment below the
lesion and there trying to discover, from rapid staining with osmic acid,
the existence of myelinised nerve fibres.
This method is far more questionable even than the former :
i. The existence of nerve fibres in the examined fragments does not
prove that the other fasciculi of the nerve are in the same condition ; the
absence of fibres in the fasciculus examined is no proof that the other
fasciculi are also affected.
2. Staining with osmic acid reveals only myelinised fibres ; now the
young fibres in course of regeneration consist, at the outset, of the axis-
cylinder alone.
3. 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 its fibres.
As regards the process of injecting methylene-blue into or above the
neuroma, in order to demonstrate its permeability to the axis-cylinders,
this would seem to be a very doubtful course to adopt.
II.— SURGICAL INTERVENTIONS
There are but three interventions possible on a nerve trunk :
Liberation ;
Suture ;
Grafting.
1. Liberation. — Liberation consists essentially in dissection of the nerve
and in ablation of the causes of compression, bony callus, fibrous tissue or
cicatricial bands.
The operation is a very delicate one, and is really satisfactory only if
* A. Sicard, Imbert. Jounlan, and Gastaud, Acad, de Med., meeting of 16 February, 19 15.
SURGICAL TREATMENT 303
we succeed in completely stripping bare the nerve cord and Liberating
from all adhesions the delicate neurilemma sheath surrounding; it.
This intervention is really permissible only when it restores a mobile,
free and supple nerve, in the interior of which there is found no obstacle
to regeneration.
It is naturally indicated in all cases of simple compression : it may be
practised in cases of ordinary neuritis. Its success is all the more likely
when intervention is prompt.
As a rule, liberation of the nerve is ineffective in cases of severe lesions
of the nerve trunk along with rupture of the laminated sheath, cicatricial
nerve keloid and formation of exuberant neuromata ; in these cases, either
the cicatricial obstacle is permeable to the regenerating axis-cylinders and
intervention is then useless, or else the obstacle does not allow of the
passage of the axis-cylinders and liberation will not make it permeable.
Seldom does liberation succeed in severe and long-standing cases of
neuritis. Almost always in such cases there are interstitial lesions of the
nerve, and on these liberation has no effect.
In all doubtful cases, remember that a good complete suture is far better
than a bad liberation.
2. Suture. — Nerve suture is indicated in all cases of complete inter-
ruption of nerve fibres where no satisfactory regeneration has taken place.
There is but one way of suturing a nerve trunk, and that is by
bringing into contact the healthy extremities of the interrupted nerve
trunk and sewing them end to end.
Suture, then, essentially presupposes resection of the cicatricial obstacle
and of all tissues which might impede the progress of the axis-cylinders.
We should bring into contact with each other a central end, containing
healthy and regularly arranged axis-cylinders, and a peripheral end, offering
for the growth of nerve fibres supple and readily permeable sheaths.
Any suture that does not fulfil these conditions is defective and almost
invariably condemned to failure. All the same, if necessary, we may
sew a supple peripheral segment on to a neuroma richly supplied with
axis-cylinders ; but we risk serious disturbances in the arrangement of
the nerve fasciculi, the systematisation of which is thus left to chance.
On the other hand, by suturing the two healthy segments, if we very
carefully avoid all torsion of the nerve, we put exactly in their right places
the different motor and sensory fasciculi and do away with all risk of
defective regeneration.
Such a suture almost invariably involves considerable shortening of the
nerve, a process which we shall be able to assist by flexion of the neigh-
bouring articulations, as indicated by Delorme.
The most effective suture is that which produces the best contact with
a minimum of traumatism for the nerve trunk. Speaking generally, it is
better to content oneself with a few stitches — silk or linen thread or even
304 NERVE WOUNDS
catgut — inserted in the neurilemma.* If the suture is tight and we are
compelled to go through the nerve, it is preferable to use only catgut,
strong enough not to tear and readily reabsorbable so as to leave no
element of irritation in the middle of the axis-cylinders.
As a rule, there is no occasion to dread secondary rupture after nerve
suture. By experiments made on animals, we know that union of the
central and peripheral segments is extremely rapid, owing to the prolifera-
tion of the neuroglial cells ; it appears to take place from the fourth day
onwards (Dustin).
Lastly, suture must ensure simple coaptation between the segments
which it unites ; a tight suture which crushes against each other the
shrivelled nerve extremities exposes the axis-cylinders to the risk of going
astray (Nageotte). Rather than incur this risk, it is better to leave between
the segments a space of one or even two millimetres, easily filled in by the
neuroglial proliferation.
Suture as thus interpreted is certainly the best operation for all serious
nerve lesions in which, along with an almost or wholly complete inter-
ruption, there exists an obstacle to regeneration.
In our opinion, it may even be recommended in certain cases of grave
neuritis from interstititial lesions, hemorrhages or fibrous infiltration. In
these cases it is better to run the risks of suture than to see the evolution
and prolongation — in spite of a liberation, which, after all, is never effica-
cious — of fibrous contractions and trophic disturbances which are so difficult
to cure.
3. Nerve grafting. — When the distance between the segments of the
nerve trunk is too great to permit of direct suture, the only legitimate
operation is nerve grafting, as recommended by J. and A. Dejerine and
Mouzon.
This consists in uniting the segments of the interrupted nerve by the
interposition of fragments removed from a sensory nerve. The musculo-
cutaneous, which to a considerable length may be removed from the leg,
is the nerve to which preference is given.
One, two, or more of these fragments, united in a bundle by catgut
passed through them, are sewn on both sides to the central and peripheral
segments. Regeneration would seem to take place through the graft some-
what more slowly than, though almost as effectively as, by direct suture.
All other grafting processes are more or less defective.
Suture by division into two is inevitably partial, since it suppresses part
of the nerve. In any case, if this suture is practised, it is always the
peripheral segment which must be divided. Division of the central end
should be altogether condemned, since it inevitably interrupts half of the
axis-cylinders. The divided fragment also should be completely detached
and sewn end to end with the two segments of the interrupted nerve.
* Catgut should be used exclusively in nerve suture. — (Ed.)
SURGICAL TREATMENT 305
Pseudo-graftings by interposition between the nerve segments of" some
tendon fibres, fragments of aponeurotic sheaths, catgut threads intended
to serve as conducting wires (?) are wholly illogical and inevitably con-
demned to failure.
There is nothing but nerve tissue that can serve as a conductor for regenerat-
ing axis-cylinders.
Defective operations. — All that we have said about the main principles
of nerve regeneration is sufficient to show how illogical and ineffective are
certain methods once strongly recommended.
All lateral sutures must be condemned that do not make continuous
the axis-cylinders of the central end and the empty sheaths of the peri-
pheral end ; lateral implantations, sutures by division into two of the
upper segment, transplantations of one nerve into the other, and more
especially transplantations of a motor nerve into a sensory one arc almost
always useless and often mischievous operations.
We must condemn the ablation of the lateral neuromata ; such inter-
vention is purposeless since it merely removes the extremity of the
regenerating nerve fibres above an interruption without supplying a guiding
channel for these fibres ; the removed lateral neuroma will inevitably form
again on the same spot, as does a neuroma in the case of an amputation.
" Combing " of the nerve must also be condemned ; it neither liberates
nor restores anything but merely effects a chance division into sections of
a few nerve fibres, the regeneration of which thus becomes a matter of
uncertainty. The only "combing" which can be advocated in some
cases is the longitudinal incision of the sheath at the level of the interstitial
hematomata occasionally found in cases of violent contusion.
Partial operations. — For partial lesions, however, we are sometimes
led to practise partial operations. For instance, we may simply suture
an interrupted bundle of a partially untouched nerve. Moreover, such
interventions can only be made on the big nerve trunks.
They may be effected by cleavage of the nerve ; its untouched part
is bent back loop-fashion to allow of direct suture of the segments shortened
by removal.
In these cases it is better, when reuniting the cut bundle, to have
recourse to grafting, except in the case of the big nerve trunks, such as
the sciatic.
Isolation of the nerves. — Care must be taken lest liberated or sutured
nerves should again be embedded and compressed by the fibrous tissue of
the scar. Several methods of preventing tin's have been recommended.
Isolation of the nerve by an aponeurotic Hap, a muscular bed, a tatty
covering, has been proposed ; catgut has been rolled round the nerve ; it
has been enveloped in a peritoneal flap or a layer of amnion ; attempts
20
3 o6 NERVE WOUNDS
have even been made to wrap round it a thin sheet of aluminium or of
rubber ; the two united fragments have been brought into a segment of a
vein or an artery ; a few drops of gomenol have been injected around the
nerve. . . .
In our opinion, these practices are almost always useless, and
even harmful in many cases, especially as regards the use of foreign
bodies.
It must be well understood that the laying bare of the nerve to a
considerable extent and the rolling round it of an isolating plate of any
kind involves the risk of diminishing vascularisation from the surrounding
tissues and thus compromising regeneration.
If we would rightly endeavour to do away with cicatricial fibrous
formations round the nerve, we must not forget that fibrous tissue may
develop at the expense of all the tissues ; muscle, fat, peritoneum, amnion
are as likely to be transformed into cicatricial tissue as the connective
tissue itself.
We give it as our opinion, therefore, that none of these practices,
speaking generally, are to be adopted. There is but one exception to
this rule, and that is when the liberated or sutured nerve happens to be
in contact with bony or periosteal surfaces capable of involving it
secondarily ; the most frequent instance is that of the musculo-spiral
liberated from the callus of a fractured humerus.
In these cases we can and ought to effect isolation of the nerve in the
vicinity of callus or a bony projection ; the best method is certainly the
interposition of a muscular — or better still a fatty — layer.
But in all other cases we look upon these proceedings as both useless
and harmful.
The best means of avoiding cicatricial fibrous formations is :
i. To avoid operating in a septic area; a nerve operation, as far as
possible, should take place only after complete cicatrisation of the wound
and when all inflammatory reaction is at an end.
2. To make a very careful hemostasis, blood infiltration being one of
the main factors in secondary fibrous formations.
3. To practise mobilisation and massage of the cicatrix very carefully
and in good time.
Alcoholisation of nerve trunks (Sicard). — The failure of all kinds of
treatment and the continuance of intolerable pain in certain cases of
severe neuritis, more especially in causalgia, have led certain authorities to
attempt the physiological interruption of the nerve.
In several cases, resection and suture of the nerve have been practised.
This succeeds quite well in serious cases of neuritis complicated with
trophic disturbances, though failure has resulted in cases of causalgia ; the
painful nerve recovers with extreme rapidity, and the causalgic syndrome
usually reappears after a few weeks.
SURGICAL TREATMENT 307
Sicard * has recommended alcoholisation of the nerve trunks, effected
by injecting above the lesion a solution of sixty per cent, alcohol. Tim
injection of one to two cubic centimetres is made in the nerve itself, after
surgical exposure.
There is thus produced by local neuritis a physiological interruption
of the nerve, which, according to Sicard, would often appear to reach only
the more fragile sensory fibres. Sicard, Pitrcs, Grinda, Godlewski, Benott,
and Morel state that they have been successful with this method.
Denudation of the arteries (Leriche). — For the treatment of causalgia,
Leriche f advocated arterial denudation and resection of the perivascular
sympathetic plexus.
This operation is based on the special nature of the pain in causalgia,
which is attributed to irritation of the sympathetic twigs supplied by the
nerve to the neighbouring artery, or else supplied to the nerve by the
periarterial sympathetic plexus.
Causalgic symptoms would appear to be largely sympathetic in their
nature, although the interpretation of these symptoms is probably some-
what complex.
We rather think there exists sympathetic irritation of a reflex nature,
for we have found such irritation extend over almost the entire region of
the cervico-dorsal sympathetic, even in the case of lesion of the median at
the wrist (pain over the entire area of" the median, constriction of the
brachial artery, diminution of the pulse, numbness of the lower part of
the face, and diminution of sweating at this level, intermittent redness
of ear on the affected side, etc.).
Under these conditions, resection of the sympathetic plexuses which
surround the brachial artery would result in the suppression of the
reflex reactions of the sympathetic which give neuralgia its distinctive
characteristics.
At all events, this procedure has given some results in obstinate cases.
The same intervention has been proposed for the femoral artery in
causalgia of the lower limb.
Sicard, Presse Medicate, I June, 1 916.
t R. Leriche, Presse Me'Jicale, 20 April, 1916.
CHAPTER XXVI
ELECTRICAL TREATMENT
Electrical treatment may fulfill three main indications ; it may :
i. Maintain contractility of the paralysed muscles.
2. Accelerate regeneration.
3. Soothe the pain.
1. The principal role of electrical treatment in paralysis is to maintain
contractility of the paralysed muscle until voluntary contraction returns.
The passing of the current attains this object by artificially bringing about
contraction of the muscle.
The current to be used, therefore, is that which will most readily and
with least intensity produce muscular contraction.
In case of reaction of degeneration, the muscle is capable of being excited
only by the galvanic current. There is polar inversion at the motor point ;
at this point, then, the positive pole would give the best contraction with
the least intensity. On the other hand, however, longitudinal excitation
is invariably greater than excitation through the motor point ; it is almost
always stronger at the negative pole. Practically, then, longitudinal excitation
by the negative pole will be used to bring about contraction of the
muscle. The galvanic current causes contraction only at the closing and
the opening of the Gurrent, consequently a rhythmic current will be
utilised, one capable of producing somewhat slow interruptions (metronome
or undulatory).
We have seen that the gradual application of the current did not
lessen its action on the paralysed muscles, whereas it suppressed the
excitation of the healthy antagonistic muscles. Besides, it is less painful
than the sudden application of the current, and permits of greater intensities
being utilised without pain. Consequently it will be a good thing always
to effect this gradual application, either by employing condensers set in
series (Lapique) or by the use of metallic undulators.
Thus a gentle and easily borne contraction will be obtained, limited
almost exclusively to the paralysed muscles and not diffused into the
healthy antagonistic muscles.
If there is no RD, the muscle can be excited by the faradic current ;
once the muscular groups can be contracted under the faradic current, we
ELECTRICAL TREATMENT 309
shall be able, with a moderate intensity, to utilise this current in effecting
contraction.
First we shall utilise the brief contractions, caused by the coil interrupter ;
then later we shall have recourse to interrupted tetanisation, set to rhythm
by the metronome, or, better still, by an undulator, though always to a very
slow beat.
In any case, whether muscular contraction is caused by the galvanic or
by the farad ic current, only a moderate effort must be required from the
paralysed muscle. As a rule, a few daily contractions are sufficient ; cart-
must be taken not to overwork a muscle disturbed in its nutrition,
which" would react by atrophy to an electrical treatment which is too
strong.
2. The simple passing of the electric current appears capable of
hastening the regeneration of the nerve, maintaining the nutrition of the
tissues and facilitating the resolution of the cicatricial fibrous tissues.
For this purpose, the galvanic current, with negative pole and of
moderate intensity, about ten or fifteen milliamperes, is generally em-
ployed. Consequently a simple galvanic bath, lasting from fifteen to
twenty minutes, can be made to precede the few rhythmic excitations
intended to maintain its contractility.
Mention must also be made of the favourable influence of the faradic
current of feeble intensity, produced by stout wire coils. This current
produces phenomena of vaso-constriction followed by intense, deep vaso-
dilatation and appearing extremely favourable to the nutrition of the
tissues as well as to regeneration.
The rhythmic faradic bath is particularly useful in the treatment of
cicatricial contractions, of muscular fibrous infiltrations, of cutaneous
adhesions and of the articular fibrous ankyloses produced by neurites, as
well as of contractions from nerve irritation.
We may advantageously bring about the association of the galvanic
and faradic currents under the galvano-faradic form ; this association
allows of excitation of the paralysed muscle whilst avoiding its fibrous
transformation ; it is by far the best treatment for muscular atrophy.
3. The galvanic current is a wonderful pain-allaying sedative, though
this property is possessed only by the positive pole. The negative pole,
on the other hand, is an excitant.
This current is utilised most frequently in the form of positive pole
galvanic baths, with intensities varying, according to the case, from five,
ten, twenty, or even twenty-five milliamperes.
Better results are frequently obtained from prolonged baths of extremely
feeble intensity ; for instance, with three and four milliamperes lasting
several hours we have obtained sedative results that shorter baths of greater
intensity could not have given.
Ionization. — Salicylated or iodised ionization has been employed with
310 NERVE WOUNDS
widely varying results in the treatment of neuritic pains and fibrous
formations.
Some good results have been obtained by ionization (i% KI solution,
negative pole) recommended by Bourguignon. The diminution of pain
effected is sometimes remarkable, though inconstant and often fleeting ;
the lessening of fibrous griffes and muscular contractions is a more constant
result.
Diathermy. — Diathermy may also be serviceable in painful and sclerosing
neuritis, and in states of ischaemia accompanied by fibrous transformation.
Radiotherapy. — Radiotherapy is often very useful in the treatment of
painful neuritis. The results we have obtained confirm the statistics
published by Cestan and Descamps ; * though in our opinion radiotherapy
has acted rather upon violent neuralgias of a causalgic type than upon the
duller pains of nerve irritation. We have seen cures effected more
especially in several cases of causalgia of the median nerve ; though
frequently the violent painful paroxysms alone have disappeared whilst
the dull pains continued.
Improvement is sometimes shown after the first treatment ; in other
cases, it appears only ofter seven or eight treatments.
It is no rare occurrence to find a momentary recrudescence of the pain,
a possibility of which the patient must be warned.
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. On this point we are unable to afford any precise
indication, for each of these methods has given favourable results after the
other has failed.
It is probable that radiotherapy applied to the lesion acts on the
inflammatory element in the nerve, interstitial infiltration and connective
tissue proliferation caused by irritation ; radiotherapy applied to the ganglia
and roots would seem to be indicated when the pain results from the state
of reflex hyper-excitability of the ganglion cells which appears to be present
in causalgia.
MECHANOTHERAPY— MASSAGE— GYMNASTICS-PROSTHESIS
However great the therapeutical resources of electricity in all its forms,
we must not forget that massage and mechanotherapy are absolutely
necessary to supplement them.
To maintain the contractility of a paralysed muscle, to prevent its
fibrous transformation, massage is perhaps as important as electrotherapy.
Daily massage should be given to every paralysed muscle.
* R. Cestan and Descamps. Radiotherapy in the treatment of certain traumatic lesions of
the nervous system. Prcssc Me'JicaU; 25 November, 191 5.
ELECTRICAL TREATMENT 311
A fortiori massage is indispensable in nerve irritations that have a
tendency to fibrous contraction of the muscle, to cutaneous adhesions and
to articular sclerosis ; it must be given in spite of the pain, unless this
latter is really intolerable. The same may be said of mobilisation which
should be practised daily in cases of neuritis accompanied by a tendency to
fibrous ankylosis. A great number of neuritic griffes, of articular fibrous
ankyloses and muscular contractions might easily be avoided by daily
mobilisation.
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, or better still, a hot bath and faradic current combined.
In addition to the passive mechanotherapy represented by massage and
mobilisation, we must also insist on the importance of the active mechano-
therapy effected by gymnastics.
This latter also maintains the contractility and nutrition of the paralysed
muscles ; it helps forward a return of the earliest movements after regene-
ration ; it facilitates and provokes the important substitutionary movements
in the case of paralysed muscles ; it mobilises the articulations and integu-
ments.
Gymnastics of the wounded limbs, in every form, both general and
particular, is thus of the utmost importance. One must have witnessed
the disastrous results of prolonged immobilisation in cases of peripheral
paralysis and neuritis to understand the supreme importance of active
movements. Inactivity of the wounded limbs and moral inertia of the
patient form the main cause of the irreducible deformities, the neuritic
contractions, the functional paralyses that accompany or follow organic
paralyses.
Finally, it is often necessary to make use of appliances of an elementary
prosthetic nature, both in order to keep the limb in its right place and to
permit of its being used in a normal fashion ; this is principally the case
with apparatus intended to correct flexion of the hand in musculo-spiral
paralysis and also steppage in paralysis of the external popliteal. Other
appliances have as their object the avoidance of fibrous contractions and
of the appearance of griffis.
All these appliances should be removable without any difficulty ; they
may readily be improvised with the aid of elastics or springs.
SCLEROLYTIC MEDICINAL TREATMENT
And lastly, some mention mu->t be made of the treatment of nerve
wounds by thiosinamin or fibrolysin (salicylate of thiosinamin).
It is logical to utilise the sclerolytic quality of thiosinamin in the treat-
ment of the cicatricial fibrous lesions compressing the injured nerve or
creating an interstitial obstacle to regeneration of the axis-cylinders.
3 i2 NERVE WOUNDS
P. Cazamian * has mentioned good results thereby ; in several instances
he would appear to have effected the disappearance of the nerve tumour
and also a certain functional improvement.
The following formula may be utilised —
Thiosinamin 15 grammes,
Antipyrin .... 7*5 grammes,
Distilled water q.s. to 150 grammes,
in subcutaneous, or better still, intra-muscular injections. Twenty-five or
thirty consecutive injections in doses of two cubic centimetres, either daily
or every other day.
Thiosinamin would seem to be specially indicated in syndromes of
compression, neuromata of attrition and neuritic types, where fibrous
infiltration of the nerve, being interstitial, is inaccessible to surgical treat-
ment ; it would also appear as though it had a favourable action on the
fibrous sequelae in cases of nerve irritation, which are so difficult to
mobilise and require so long a time.
* Cazamian. Presse Me'dicale, 11 November, 191 5.
INDEX
Action, polar, in electro-physiology, 49
Alcohol, injection of, 306
Amesthesia, deep and cutaneous, 31-33
chloroform, 86
complete ulnar, 168
from lesion of posterior tibial, 255
in complete section of ulnar, 142
in lumbar hematomyelia, 295
in musculo-spiral paralysis, 107
in section of circumflex, 204
of cutaneous area, 166
of external cutaneous nerve of thigh,
277
of hand, 193
peripheral, 92
segmentary, 93, 97
thermal, 78
Andre-Thomas, xii, 75
Anterior crural nerve,
collateral and terminal branches, 268-
271
diagnosis of paralysis of, 273
paralysis of, 271-272
Anterior tibial nerve, paralysis ot, 247-248
Aponeuroses, 29
Apparatus, Sollier's, 130
of Leri, 265
of Le>i and Dagnan-Bouveret, 131
of Marie and Meige, 265
of Mauchet and Anceau, 131
of Robin-Chiray, 265
Appendages, skin, 29
Aran-Duchenne syndrome, 218
Arteries, denudation of, 307
Athanassio-Benisty, xii, 73, 77, 82, 191
Atropy, massive, 30
muscular, 21
I!
Babinski, xii, 40, 82, 86, S8, 166
Benoit, 307
Bergonie, 59
Bielchowski, method of, 13
Bordier, 59
Bourguignon, 5c, 55, 310
Brachial plexus, 209
branches of, 212-214
connexions of, 2 1 1
lesions of, 214-215
primary and secondary trunks, 210
radicular syndromes (roots and primary
trunks), 215-224
Broca, xii
Cardot, 49
Causalgia, 66, 1 87—19 1
Cazamian, 312
Cestan, 310
Charcot clinic, vii
Clironaxie, 53-59
Chronaximetrc of Lapicque, 57-58
Circumflex nerve, 201
branches, 202-203
paralysis of, 203-204
sensory disturbances in paralysis of, 204
Claude, xii, 82, 176, 181, 195
Club-foot, 88, 90
Cluzet, 55
Compression of nerve, 2
Contractility, mechanical, of muscle, 23
Contraction, fibrous, of muscles, 24
club-foot from, 90
from nerve irritation, 73
Contracture, 83
from neuritis, 88-91
functional, 86, 91
of hand in flexion, 84
of interossei and hypothenar eminence,
Contusion ot nerve, 2
Cruveilbier, 231, 239
Current, faradic, 37-40
galvanic, 40-45
1)
Decalcification, 30
Degeneration, Wallerian, 5, 13, 61, 74
Dejerine, xii, 3, 11, 14, 15, 21, 23, 33, 60,
62, 65, 117, 147, 159, 160, 180, 188,
189, 245, 246, 255, 304
3H
INDEX
Delherm, 40
Delorme, 302
Descamps, 310
Desquamation, cutaneous, 310
Diagnosis of nerve lesions, 15
Diathermy, 310
Disturbances, cutaneous, 25
thermal, 28
vaso-motor, 27
Doumer-Huet, longitudinal reaction or', 45
Dubois, 93
Duchenne of Boulogne, xii, 37, 39, 149
Dupuytren's contracture, 70, 156, 157
Dustin, 304
Electrical treatment in paralysis, 308-
309
Engelmann, 53
Erb, paradox of, 39
Erb-Duchenne syndrome, 216
Examination, faradic, 37-40
galvanic, 40-45
Excitability, latent faradic, 40
Excitation, selective, of paralyzed muscles,
58-59
External cutaneous nerve of thigh, 277-278
External plantar nerve, 241
External popliteal nerve, 233
clinical forms of paralysis of, 245
collateral and terminal branches, 234-
237
motor syndrome, 242-243
paralysis of, 242
sensory syndrome, 244
trophic and vaso-motor syndrome, 244
External saphenous nerve, 257
Fibrous infiltration of muscles, 70
Foix, xii, 49
Formication, 18
provoked by pressure, 34
Froment, xii, 82, 86, 166
Galvano-tonus, 52
Genito-crural nerve, lesions of, 279
Glioma, 1, 4, 9-1 1, 15
Glossy-skin, 72, 97
Godlewski, 307
"Goniometer," 19
Gosset, 301
Grafting of nerve, 304
Granular bodies, 5
Griff e, 19, 24,68-69,96,98,145-169,255,
257, 3io» 3 11
Grinda, 307
Gymnastics, 310
H
Hjematomyelia, 92
Head, 79
Henle, loop of, 213
Histology, 5-15
Hunter's canal, 270
Hyperesthesia, 32, 69
Hypertonia, 73
Hypertrichosis, 29
Hypoassthesia, 32, 33
Hypothenar eminence, atrophy of, 13!
Ilio-hypogastric nerve, 280-281
Ilio-inguinal nerve, 280-281
Indications for operation, 299
Integuments, examination of, 25
Internal cutaneous nerves, 205
lesions of, 206-207
Internal plantar nerve, 24c
Internal popliteal nerve, 237-239
collateral and terminal branches, 239-
242
grave neuritic type, 253
motor syndrome, 250-251
sensory syndrome, 251
simple neuralgic type, 254
slight neuritic type, 253
trophic and vaso-motor syndrome, 251-
252
Internal saphenous nerve, lesions of, 272-
2 73.
Ionization, salicylated, in treatment of
neuritic pains, 109-110
Ischemic paralysis, 96-98, 223
of upper limb, 225-229
Jarkovski, 40
Jeanne, 153
Jolly, 48
Jumenti£, xii
K
Keloids, nerve, v, 3, 11
Lantermann, incisures of, 12, 13
Lapicque, 53-59
Lasegne's sign, 70, 259
Laugier, 49, 55-57
Lejars, xii
Lemoing's glove, 130
Leriche, 73, 191, 192, 307
Lesser internal cutaneous nerve, 206
INDEX
3*5
Letievant, xii
Liberation of nerve, 302
Ligament, Poupart's, 268, 272, 279
Lumbar roots, 289-290
Lumbo-sacral plexus, 282-286
diagnosis of the lesions or, 294-296
radicular syndromes of, 287-289
M
Marchi, 5
Marie, P., xii, 40, 49, 77, 117, 130, 301
Massage, 310
Mechanotherapy, 310
Median nerve,
anastomotic branch, 174
anatomy of 170
causalgia of, 187-193
complete paralysis above epitrochlear
muscles, 178-182
diagnosis of paralysis of, 192
dissociated paralysis of, 183-185
motor branches, 172
motor syndrome, 175
neuritis of, 185-187
paralysis below epitrochlear muscles,
182-183
sensory branches, 173
sensory syndrome, 176
trophic syndrome, 177
Median and ulnar nerves, associated para-
lysis of, 194-196
Meige, xii, 40, 73, 77, 82, 117, 130, 191,
301
Morel, 307
Motor points, 41, 42, 43
descent of, 52
Mouzon, xii, 14, 15, 21, 23, 33, 60, 65,
117, 147, 159, 160, 189, 245, 246, 304
Muscle, mechanical contractility of, 23
fibrous contraction of, 24
sensibility to pressure, 23
Muscles, interosseous, 138
Muscular atrophy, 2 1
contraction and hypertonia, 24
tone, 21-22
Musculo-cutaneous nerve, 197
branches, 198, 199
isolated paralysis of, 248-249
motor and sensory syndromes, 200
paralysis of, 200
Musculo-spiral nerve,
anastomotic branches, 103
anatomy of, 99
diagnosis or musculo-spiral paialysis,
126
dissociated paralysis of, 1 16
dissociation of extensor communis digi-
torum, 1 15
motor branches, 102
motor syndrome, 104
paralysis above supinator longus, no
Musculo-spinal nerve — continue J
paralysis below extensor communis
digitorum, 1 16
paralysis below radial extensors, 1 14
paralysis below supinator longus, 112
paralysis of, 104
partial paralysis of triceps, 109
sensory branches, 102
sensory syndrome, 107
syndrome of compression, 118
syndrome of interruption, 1 19
syndrome of nerve irritation, 121
syndrome of regeneration, 1 24
total paralysis of, 109
treatment, 129
trophic syndrome; 108
N
Nageotte, xii, 4, 9, 304
Nails, changes in, 29
Nerve, sections of, 1, 7
anatomy of, 99-103
dissection of, 302
grafting, 303
isolation of, 305-306
liberation of, 302
musculo-spiral, 99-131
physiology of, 104-117
suture of, 302
Nerves, musculo-spiral, 99
anterior crural, 268
circumflex, 201
external cutaneous nerve of thigh, 277
genito-crural, 279
ilio-hypogastric, 280
internal cutaneous, 205
lesser internal cutaneous, 206
median, 170
musculo-cutaneous, 197
obturator, 275
sciatic, 231
small sciatic, 266
ulnar, 132
Nerve trunks, alcoholization of, 306
Neuritis, ascending, 81-82
paralysis, hypertonia and contraction
from, 82-91
Neuroma, 1-4, 7-16, 35-36
Neurotropism, 6, 7
O
Obturator nerve, 275
superficial ami deep branches, 276
CEderaa, 27
of hand, 108
Operations, defective and partial, 305
choice of, 301
indications for, 300
time of, 300
316
INDEX
Pain, spontaneous, 65
provoked by pressure, 65
Palsy, crutch, 99
"Saturday night," 99
Paralysis, 18-30
apparatus for, 1 30-1 31
central, 92
diagnosis of, 164-165
from pseudarthrosis, 95
functional, 93-96
hysterical, 97
ischaemic, 96
musculo-spiral, 104-128
pseudo-, 95
simple compression of, 144
treatment of, 129-130
ulnar, 136-165
Peripheral nerve lesions,
treatment of, 297-299
Peroncito, 8
Pes equinus, 24, 69, 88, 95, 253, 259, 261
Petres, 243, 250, 307
Philippeaux, xii
Pole, action, 50
negative, 51
positive, 51
Posterior tibial nerve, paralysis of, 255
Prosthesis, 311
Pseudo-^r^, 164
Pseudo-neuroma, 2, 3, 4, 12, 15
Pudendal plexus, 286-287
R
prognosis and
Radiograph of hand, 30
Radiotherapy, 191, 310
Reaction of degeneration, 39
complete, 45
partial, 47
Reaction, sweat, 26
longitudinal, 52
myotonic, 48
of exhaustion, 48
Reflexes, 20
Revue Neurologiqut, xii
Roth, W., 278
Sacral roots, 291—293
Schwann, sheath of, 5, 1 3
Sciatic nerve, anatomy of, 231
collateral and terminal branches, 232-
233
diagnosis of paralysis of, 262-264
paralysis of, 242-257
treatment of paralysis of, 264-265
Sciatic trunk, paralysis of, 257-262
Sclerolytic medicinal treatment of nerve
wounds, 31 1-3 1 2
Sensibility, of muscle to pressure, 23
attitude, 33
cutaneous, 31
deep, 33
of nerve on pressure, 34
osseous, 33
Sheaths, synovial, 29
Sicard, xii, 23, 82, 191, 302, 306, 307
Small sciatic nerve, collateral and terminal
branches, 266-267
Societe de Chirurgie de Paris, xii
Societe de Neurologie de Paris, xii
Steppage, 243, 257
Stimulation, unipolar, 37
bipolar, 37
Surgical intervention, time of, 300
choice of, 301-307
Suture of nerve, 303-304
Syndrome of nerve interruption, 45, 61-63
dissociated, 80-8 1
of compression, 46, 63-66
. of fibrous transformation, 47
of nerve irritation, 67-73
of regeneration, 73-79
Tendons, 29
Tenotomy, 24
Testut, 243, 250
Thenar eminence, 140
atrophy of, 182
Thiosinamin in treatment of nerve wounds,
311-312
Thomsen's disease, 48
Tone, muscular, 21, 22, 23
Treatment, electrical, 308
Triangle, Scarpa's, 268, 273, 279
Trophic changes, 25, 65, 68, 69, 80
U
Ulceration, 28
Ulnar nerve, anatomy, 132
contractions resulting from slight neu-
ritis of, 165
dissociated syndromes, 158
motor branches of, 133-134
motor syndrome of ulnar paralysis, 136
neuralgia of, 158
neuritis of, 165
physiology of, 136
sensory branches of, 135-136
sensory syndrome, 141
simple compression or recent interrup-
tion of, 144
syndrome of prolonged complete inter-
ruption, 149
syndrome of nerve irritation, 154
trophic and vaso-motor syndrome, 142
INDEX
3*7
Upper limb, ischemic paralysis or, 225
characteristics of, 226-228
diagnosis of, 228-229
Valleix, points, 70, 259
Vaso-motor changes, 27
Velpeau, quadrilateral square of, 201
Velter, xii
Vulpian, >ii
W
Waller, xii
Weir Mitchell, S., xii, 66, 71-72, 187
Weiss, 53
Wound, examination of, 17
date of, 1 7
investigation of first sequelae of, 18
nerve disturbances of, 18
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