y   tdi
OBSERVATIONS IN  FIVE HUNDRED CASES OF INJURIES OF
     THE  PERIPHERAL NERVES AT  U.  S. A.  GENERAL
                     HOSPITAL NO.  11

          By Lieutenant Colonel CHARLES H. FRAZIER, M.C., U. S. A.
                             and
             First Lieutenant SAMUEL SILBERT, M.C., U. S. A.
             Reprint from
SURGERY, GYNECOLOGY AND OBSTETRICS
        January, 1920, pages 50-63 
NATIONAL LIBRARY OF MEDICINE
        Bethesda, Maryland

              Gift of

       Edward B. Schlesinger
 
OBSERVATIONS  IN  FIVE  HUNDRED   CASES  OF  INJURIES  OF  THE
    PERIPHERAL  NERVES AT U.S.A. GENERAL HOSPITAL  NO. 11*
          By Lieutenant Colonel CHARLES H. FRAZIER, M.C., U.S.A. and First Lieutenant
                              SAMUEL SILBERT, M.C., U.S.A.
      OF the 208,000 casualties in the American
        Expeditionary. Force, there were "in
        the  general  and  base  hospitals  in
this  country in April,  1919, 3,000 patients
with  peripheral  nerve injuries.   Assuming
that 15 per cent of the total admissions had
been discharged by this time—a conservative
estimate—there  were  altogether  approxi-
mately  4,500 peripheral nerve injuries or 1.6
per cent of the total casualties.
  With but few exceptions, the treatment of
peripheral nerve injuries did not begin until
the soldiers from overseas became patients
on this side of the Atlantic.  Obviously this
was a problem which belonged to the recon-
struction hospitals and not  to the hospitals
of the war zones.  In more than  500 cases
admitted to General Hospital  No. 11, there
were not more than 5 cases in which the nerve
had been sutured overseas.
  The  Surgeon General  recognized in  the
management of peripheral nerve injuries a
problem quite distinct from that either  of
general or orthopedic hospital and authorized
the organization of ten peripheral nerve cen-
ters, in as many general hospitals, to which
all patients were to be transferred from the
ports of debarkation or later from base hos-
pitals, to  which a number found their way
with lesions of the nerves unrecognized at the
time of their admission.  In each of these pe-
ripheral nerve centers an officer, experienced in
neurological surgery, was assigned and a con-
sulting  neurologist and equipment essential
for examination and treatment were provided.
As  an  additional  recognition of the impor-
tance of the peripheral nerve problem,  the
Surgeon General approved the organization
of a Peripheral Nerve Commission, selected
the personnel,  and issued  instructions as to
the scope of its work.  Among other things
this commission will prepare for the Surgeon
General a comprehensive report dealing with
the various aspects of peripheral  nerve in-
juries and the results obtained by treatment.
  * The views expressed in the observations recorded in this article represent those of my associates on the staff as well as my own. I am indebted
to the cordial co-operation of Majors Coleman and Selling, Captains Ingham, Kraus, and King, First Lieutenants Arnett, Anderson, Baird, Behnev,
Buerki, Cobb, Hobson, Kennedy, McCutcheon and Silbert.
  It has been my privilege as consultant in
neuro-surgery to the Surgeon General's office,
to visit the clinics in many of the peripheral
nerve centers, but the views herein expressed
will  be based  more particularly upon the
observations  of between five and six hundred
cases under my direct supervision at General
Hospital No. 11 (Table I).
  To  systematize  the  preparation  of 'the
clinical records, printed forms were prepared,
afterward adopted by the commission as the
authorized form for all the peripheral nerve
centers.  A   technique  of  examination  was
elaborated, special instruments were designed,
and  instructions  were issued as to how the
phenomena were  to be elicited and recorded.
Orders were  issued that duplicate copies of
all clinical records  be furnished to the Sur-
geon General's office so that the Commission
might  have,  as the basis for its final report
to the Surgeon General, complete and uni-
form records of all peripheral  nerve lesions
standardized  as to methods of  examination
and record.

          SENSORY PHENOMENA
  With regard  to observations  upon  dis-
turbances,  we  disregarded  the  theory  of
Head  and his  well known classification of
"epicritic" and "protopathic" sensory loss.
The  subsequent experiments of Trotter and
Davis1 and later of Boring2 proved the fallacy
of Head's theory and disproved the idea that
there are separate fiber systems for moderate
(epicritic)  and  for extreme  (protopathic)
temperature,  tactile, and   pain  sensibility.
Furthermore, the clinical observations  from
the wealth of material, provided by the four
years of war, may  be cited in refutation of
Head's classification. Lieutenant Cobb, from
his review of the literature and from his study
of the  problems in our clinic, concluded that
dissociations  of sensation due  to  peripheral
 ' J. Physiol., 1000,  xxxviii, 134.
 2 Quart. J. Exp. Physiol.,  1916, x. 1. 
2
SURGERY, GYNECOLOGY AND OBSTETRICS
TABLK I.--TABLE SHOWING NERVES INVOLVED

          IN A SERIES OF 400 CASES

                Upper extremity

I'lnar.....................................  112
M usculospiral..................................  06
Median........................................  88
Brachial  plexus.................................  37
Musculocutaneous..............................  13
Facial.........................................  13
Internal cutaneous.............................   9
Circumflex.....................................   S
Radial........................................   2
Lingual.......................................   1
Hypoglossal....................................   1
Supraspinatus..................................   1
 Per-
centage
 22
 18.q
 17-3
  7-2
(§LA$)
Total.......... 378
Lower Extremity
 Per-
centage
 10.4
 10.4
  2.1
Sciatic.........................................  S3
External popliteal...............................  S3
Internal popliteal................................  n
Anterior tibial..................................  4
Posterior tibial..................................  2
Lumbar plexus.................................  3
Small sciatic....................................  1
Anterior crural..................................  1
Musculocutaneous...............................  1

                      Total.......... i2g
nerve lesions  arose  from comparing stimuli,
not only  quantitatively different but quali-
tatively unequivalent.  By varying the quan-
titative values of the stimuli, dissociations of
sensations could be  produced almost  at will.
In short  they are artefacts  due to lack of
proper standardization  of  the  examination.
Hence, it  became apparent  that in the exam-
ination  of disturbed sensation, standardized
instruments had  to be  employed and  the
examinations  conducted under  uniform con-
ditions. If the hmb  was cold at one examina-
tion and warm at another,  there would be a
difference of 0.5 centimeters to 2.0 centimeters
in the ulnar and  even 5 centimeters in the
sciatic distribution.
  Upon the adoption of standardized algesim-
eters and a uniform technique, it was found
that in the examination of an individual case
by different members of the staff the sensory
charts were precisely  similar (Fig. 1). The
technique  included:
  a. An examination  for  tactile  sensibihty
with a camel's hair brush, so  pliable that the
skin could not be depressed.  Loss to tactile
sensibihty was indicated on the chart by Unes
representing the stroke of  the  brush.
  b. Test for pain sense with an algesimeter
with 15 grams' pressure, indicated when lost
by large dots on the  sensory chart (see Fig. 2).
  c. Test for  deep sensibihty by an algesim-
  Fig. 1.  .-Esthesimeters devised at U. S. A.  (lencral
Hospital No. 11 by Captain Ingham.

eter with 1000 grams' pressure indicated when
lost by small dots or sohd black  (see Fig. 2).

         ELECTRICAL EXAMINATIONS
  Electrical stimulation of muscles or nerves
at  the  evacuation  or base  hospital  is  an
invaluable aid in distinguishing the organic
from the functional paralysis.  In  the  recon-
struction hospital where  the patients are re-
ceived 3 to 6  months after the injury, the
value of the electrical examination is twofold:
(1)  to observe evidences of recovery,  (2) to
determine whether the condition is stationary
or retrogressive.   In recording the electrical
findings, a special chart is used and instruc-
tions issued  to all  peripheral nerve centers
as  to how the findings  are to be recorded
(Fig. 3).  We eliminated the terms "Reaction
of Degeneration" as indicating conclusions
rather than observations and  instructed the
examiner to record precisely what he elicited:
(1)   whether  "faradic"   contractions  were
"normal," "weak"  or "absent," and  (2) in
the galvanic stimulation the rapidity  of the
contractions and  relaxations and the presence
or absence of  reversals.  By this  system of
record, comparisons  could be  made between
examinations of different dates.  The instru-
ment supplied  to all peripheral nerve centers
was the Wappler galvanic and faradic plate.
The investigation and interpretation  of the
electrical findings at General Hospital No. 11
is under the direction of Lieutenant Silbert,
and the following are some of his deductions:
  1.  The loss of skin sensibihty  to faradic
current is fairly good evidence  of complete
interruption.   Tinel's observation that the
return of skin sensibihty is the  earliest sign
of nerve regeneration has been confirmed by
the examinations in this clinic.
  2.  Occasionally the loss of skin sensibihty
is incomplete  in  cases  proved at  operation 
FRAZIER:  PERIPHERAL  NERVE INJURIES
3
   Loss of touch to
   camel's hair brush
FTx] Loss of pain to
&M 15 gm. prick-
f/l Loss of pressure
   of 1000 gms.
V.
  Fig.  2. Chart showing method of  recording sensory
examination.
to be complete interruption.  This phenome-
non has  been  attributed to the presence of
anastomotic  communications  between  the
nerves below the level of the lesion.
  3.  Faradic response may be lost even in
incomplete  and mild lesions, and  such  as
those of  moderate  contusion,  and is, there-
fore, of little value in a decision for or against
operation.   With but one  exception in  the
operative series and in but  three of all other
cases did voluntary motion  not return before
that of response to the faradic current.
            Form Wd
       Mm cav dtpabtmeht, U- 8. Aim
         AtftborlMd Ju. 17. 1916.)


        CLINICAL RECORD

     SUBJECTIVE SYMPTOMS

U-sXcewr.! H<*pl«J No. 11, Cape May.N. J. 5-20  1919
 Condition on admuaon:
            Lt. Silbert   e**»i»«

    PERIPHERAL NERVE REGISTER (No. 2)


       ELECTRICAL REACTIONS

 (Tell only when the aty It warn; compare contraction! with opposite
tide. Faradic; oote normal, weak, or abaeot contraction). GaJvaoi*
Mine. also m. a. en.pt -yed. rapidity ol contraction! and reliction., «
tick reaction! and .esence oa abience of rereraali).
Pan teated	F.r.dic	Gil.inic
»««.		
Ext. Pop.	Absent	Absent
Int. Pop.	Present	Present insertion in tendon)
Post. Tib

Ant. Tib.


Peroneals
Intrinsic
 muscles
Absent
Quick, normal

Slow & wavy, non-
tetanic, reversal

Slow & wavy, non-
tetanic, reversal
Quick, normal
Johnson
  Fig.  3. Chart showing method of recording electrical
examination.

  4.  Stimulation by galvanism applied over
the  course of the  damaged  nerve  uniformly
fails to give a response in the muscles below
the level of the injury.
  5.  The following  deductions are  drawn
from  the  apphcation of  galvanism  to  the
muscles supplied by the damaged nerve:
  a. The  maximum response is usually over
TABLE  11.
SUMMARY OF ELECTRICAL EXAMINATIONS IN  IOO CASES  OPERATED UPON
	Faradic						Galvanic											
	Area of loss of skin sensibility			Muscle response			Nerve response			Muscle response								
										Slow			Tetanic			Reversal		
	Pres-ent	Ab-sent	Not re-corded	Pres-ent	Ab-sent	Not re-corded	Pres-ent	Ab-sent	Not re-corded	Pres-ent	Ab-sent	Not re-corded	Pres-ent	Ab-sent	Not re-corded	Pres-ent	Ab-sent	Not re-corded
Compres-sion	1	3	6	0	10	0	0	10	0	9	0	1	1	S	4	1	4	S
Neuroma	20	17	IS	0	52	0	0	SO	0	SO	0	2	6	30	16	n	38	3
Interrup-tion	13	8	17	0	36	2	0	36	2	36	0	2	1	27	10	20	IS	3
 
4
SURGERY, GYNECOLOGY  AND  OBSTETRICS
	Symptom		Pathology | 10 20 30 40 60 60 TO 80 90								
Fin die	Area of loss of skin sensibility		......«■ | |								
			»ui.>ni.i								
			):iK<rrun!„,nH								
	Abf.n<-» «* muscle response		Comprr .-.lun^H Neuroma H								
			Interruption ■								
Galvanic	Absence of nerve response		Compression ^1								
			Neuroma								
			Interruption §_								
	mus-cle re-sponse	slow tetanic reversal	Compression^!								
			Neuroma								
			InterruptionH								
			Cmp-csmnB								
			S'-ur.,m.l								
			l,v..rr,p...,n W								
			Jompiessiun^l								
			Nturima 1								
			Interruption ^M								
Table III.  Summary of electrical examinations in ioo cases operated upon.
the tendon of the muscle or at the junction of
tendon  to muscle  belly  and not as in  the
normal  muscle at the motor point.
  b. The rapidity  of contraction is the best
guide  to the  degree  of  degeneration;  the
slower  the  reaction  the  more  complete  the
degeneration.
  c. Tetanic response is observed occasionally
but its  significance is not clear.
  d. The reversal of polarity  is  the  most
valuable  of all phenomena.   Though  not
invariably yet in the majority of cases reversal
signifies anatomical  interruption.
  e. Reversal of polarity is occasionally seen
in normal muscles  (see Tables II and III).

  TROPHIC AND VASOMOTOR DISTURBANCES
  Trophic  and  vasomotor  disturbances of
peripheral nerve lesions,  are frequently ob-
served  but are of  comparatively  little prac-
tical importance, as affecting diagnosis, prog-
nosis,  or treatment.  Capsular  and muscle
fibrosis are the most serious  complications of
peripheral nerve lesions  and they are  intro-
duced  in this  connection because so  often
vaguely  attributed   to  trophic  influences.
This disability arising from these two factors
is extreme  and unless reheved  the regenera-
tion of the  injured nerve will avail but little.
For reasons not clear  the metacarpophalangeal
joints are the most  seriously involved.  The
cause of these crippling lesions in muscle and
joint has been the object of  an investigation
in  our  clinic by Major  Selling, and he has
come  to these conclusions: (i)  In uncom-
plicated  lesions there  is  no   limitation of
passive motion, except  that which  results
from  shortening  of the  paralyzed  muscle,
when the hmb  is properly sphnted.  This is
of minor importance as the disability is soon
overcome after  the muscles  have  regained
their function.  (2) When nerve injury is com-
plicated by fracture, prolonged  immobiliza-
tion and particularly by suppuration in the
healing process, the result is often capsular
fibrosis no matter what the  nerve involved,
whether  musculospiral,  ulnar   or   median.
(3) If,  however, there is  a serious vascular
lesion  of the  main  arterial trunks, added to
the capsular fibrosis, there is extensive muscle
fibrosis and the combination of these is re-
sponsible for the extreme limitation of mo-
tion.   The  fact that  in  median and ulnar
lesions of the arm,  there is greater likelihood
of involvement of  the main  arterial trunks
accounts for the  fact that  these  crippling
deformities are seen more often in median
and ulnar than in musculospiral lesions; and
the same line of reasoning may be applied to

TABLE  IV.--FACTORS INVOLVED IN LIMITATION
                OF MOVEMENT
  1. Direct damage—joint and muscle.
  2. Fibrosis and shortening paralyzed muscle.
  3. Adaptive shortening normal muscle.
  4. Capsular fibrosis.
  5. General muscle fibrosis.
 Nerve lesion.
Uncomplicated
2. Complicated by
   a. fracture
   b. immobilization
   c. suppuration
3. Complicated by  .
   vascular lesion
 Limitation Joint Movement.

a. absent
b. due to shortening of paralyzed
   muscles
Capsular fibrosis
Other factors secondary
Capsular fibrosis
Extensive muscle fibrosis and short-
 ening. 
FRAZIER: PERIPHERAL NERVE  INJURIES
5
TABLE  V.—-FACTORS  IN  JOINT  LIMITATIONS  IN  A  SERIES  REPRESENTING  THE
                    MUSCULOSPIRAL, MEDIAN, AND  ULNAR
	Lesion	Location	Fracture	Suppura-tion	Immo-biliza-tion	Vascular	Elbcw	Wrist		Fingers Limited Movt. Due to	
								Flex.	Ext.		
w. c.	M. S.	Arm	0	0	0 +	0	0	+ + +	0	0	Wrist flexion; shortening of ex-tensors.
w. c.	Med.	Axilla	0	0	0	0	+ +	0	+ +	0	Elbow direct injury. Wrist ext.; shortening of flexors.
P. H.	U.	Arm	O	0	0	0	0	0	+	0	Wrist ext.; shortening of flexors.
H. D.	M. S.	Arm	Humerus	+ + +	+ + +	0	+++	+ + +	+ +	++	Joint involvement (capsular fibrosis) all joints.
E. E.	Med.	Arm	Elbow	+ + +	+ + +	0	+ + + +	+ + +	+++	+ + +	Joint involvement all joints. Elbow direct injury; others capsular fibrosis.
B. H.	Ulnar	Arm	Elbow	+++	.+++	0	+ + + +	+++	+++	+ +	Joint involvement all joints. Elbow direct injury; others capsular fibrosis.
H. H.	Med. Ulnar	Arm	0	+	+ +	Oblit. Brachial Artery	++ +	+ ++	+++	+ + +	Joint involvement all joints Capsu-lar fibrosis and extensive muscle fibrosis.
the lower extremity, where  the  most com-
monly affected  nerve, the  sciatic,  is  not
accompanied with  an  injury  of the large
vascular  trunks  (see Tables IV and V).

      PATHOLOGICAL CONSIDERATIONS
  The pathology of peripheral nerve lesions
was not  overlooked in the turmoil of war,
and of the noteworthy investigations mention
should be made particularly of those of Cone
and those of Huber, to whose direction the
Surgeon  General assigned the experimental
study of nerve  regeneration, as applied to
nerve suture, and the minute examination of
the pathological material  removed  at opera-
tion in the several  peripheral nerve centers.
The various types of lesions have been classi-
fied under five headings.
  i.  Complete anatomical interruption
       a. with central bulb,
       b. with central and peripheral bulb;
      Neuroma in continuity
       a. central bulb;
       b. lateral bulb;
      Partial anatomical interruption  (lateral
         notch);
      Sclerosis;
      Compression
       a. by callus, bone spiculi,
       b. by aneurism,
       c. by scar tissue.
2.
4-
5-
  The pathological  investigations  in our
clinic have been made, apart from the routine
examination of specimens, chiefly along two
lines; the topographical study  of specimens
removed  with relation to the results of elec-
trical stimulation on the operating table, and
the distribution of motor and sensory dis-
turbances and the  correlation of pathological
and electrical findings.
  With regard to the latter, the complete
and incomplete sensory, motor, and electrical
findings  have been tabulated  in Table VI
with  relation  to the three essential lesions:
compression,  neuroma  in  continuity and
complete  anatomical interruption.  It is  of
interest to note that in the majority  of in-
stances  a careful examination  of motor,
sensory,  and electrical disturbances  foretold
the  character of  the  lesion found  on the
operating table.   Thus (i)  in  compression
there was complete motor paralysis in 45 per
cent, complete sensory loss in 15 per cent, and
no case with complete reactions of degenera-
tion.  (2) Incomplete anatomical interruption
there was complete motor loss in 100 per cent,
complete sensory loss in 86 per cent and com-
plete reactions of degeneration in 85 per cent.
(The absence of  complete  sensory loss  or
reaction  of degeneration in the minority may
be attributable  to the fact  that in the scar
tissue intervening between  the  divided seg- 
6
SURGERY, GYNECOLOGY  AND  OBSTETRICS
  Table VI. Showing percentage of incomplete and complete motor, sensory, and
electrical syndromes in compression, C, neuroma in continuity, N, and anatomical
interruption, 7.
ments a few indistinguishable fibers may have
been present.) (3) The neuroma in continuity
presented a  picture,  as one  might expect,
intermediate  between compression and com-
plete  interruption.  Thus there was complete
motor loss in only 74  per cent, incomplete in
26 per cent; complete sensory loss in only 33
per cent, incomplete in 67 per cent; complete
reaction of degeneration in 16.5  per cent, in-
complete in 83.5 per  cent.

           TIME OF  OPERATION
  The determination when to  operate  is a
matter of vital importance. Without fear of
contradiction  it  can  be  assumed  that  the
sooner the operation  the  better, but from
indiscriminate, hasty  resort to operation one

TABLE VII.--SHOWING THE  FIRST RECORDED
   SIGNS OF  RECOVERY  IN A SERIES OF
                 400  CASES
                                       Per-
                                Cases  centage
2 months.......................................  13     3
3 months.......................................  34     8.5
4 months.......................................  71    17-7
5 months......................................  77    IQ-4
6 months.......................................  67    16.8
7 months.......................................  61    IS-3
8 months.......................................  45    n-3
Over 8 months..................................  32     8
                                400
must  refrain for two reasons: (1) because
many cases will  recover  spontaneously;  (2)
because the presence of an  infected wound
necessitates postponement.   Looking at  the
statistics in our own  clinic,  we find that  the
first signs of recovery were not observed in a
number of cases until 8 months after the in-
jury (see Table VII).  Of the recovering cases,
36 showed the first signs of recovery in  the
fifth and sixth  month, and 26 in the seventh
and eighth month.  From these figures and
those in the table it  would  be evidently  un-
justifiable  to  resort  to operation, at  least
until six months had elapsed, and there might
in view of these figures be some justification
for waiting a month or two  longer.  The per-
centage of spontaneous recoveries  may vary
in  different clinics.   At  General  Hospital
No. 11, taking the last 400  cases,  254  or 63
per cent had recovered sufficiently to be  dis-
charged or were in the recovery stage, 112 or
28  per  cent had been operated upon and 9
per cent were stationary  and unimproved
(Table VIII).
  Viewed from the standpoint of  the condi-
tion of the wound, the advisability of waiting
until  the wound has been  healed  3 months
has been recognized as a wise precautionary 
FRAZIER: PERIPHERAL  NERVE INJURIES
7
TABLE VIII.--SHOWING THE DISPOSITION  OF
           A SERIES  OF 400 CASES
Cases discharged—
 Operated upon..................................   3
 Not operated upon..............................  125    128
Cases remaining—
 Operated upon..................................  109
 Not operated upon.................................
   Improving....................................  12Q
   Stationary....................................   34    272
                        Total..................  400

measure.   This has  been our practice,  and
the fact that there have been but three  in-
fections in over ioo elaborate, extensive and
prolonged  dissections,  often  through poorly
nourished  tissue and extensive cicatrization,
would appear  to justify the adoption of  the
three month rule.   Two of these wound in-
fections were superficial and could not have
affected  the process of regeneration at  the
line of suture; in one  instance recovery  has
been complete.  Applying the three month
rule to our own cases (see Table IX)  the time
of operation .would have been deferred to  the
end of the fourth month in 33  per cent of
cases, to the end of the fifth and sixth month
in 44 per cent, and to the end of the seventh
and  eighth month in 15  per cent.  Apart
from the interpretation of chnical phenomena
as indicative of a complete physiological block,
these two factors, the  chance of spontaneous
recovery and the three month rule, are often
the decisive factor  in  determining how soon
the patient should  be operated upon.

          METHODS  OF PROCEDURE
   Splinting.  In the organization of a periph-
eral nerve clinic, provision must be made for
the care of those cases in which spontaneous
recovery has  already  begun  as  well as  for
those in which the necessity for  operation is
still  under  consideration.  The  importance
of  keeping the muscle in a state of rest  was
recognized long before the war and in lesions
other than peripheral nerve palsies. It  had
been  observed in  the paralysis of anterior
pohomyehtis that when muscles were kept at
rest by  proper apparatus, recovery of func-
tion was more prompt in the first place  and
in  the  end  more  complete.  This general
principle was recognized in  the case of  the
peripheral nerve palsies,  but there is a three-
fold  purpose  in the employment of splints.
TABLE IX
Time it took wound to heal in a
   series of 400 cases
                Cases
1 month or less..........  126
2 months................  90
3 months................  74
4 months................  36
5 months................  26
6 months................  17
7 months................   6
8 months................   6
9 months or over.........  ig

     Total...........  400
Time of operation if performed
 3 months after wound healed
            Percentage
 4 months...........  31.5
 5 months...........  22.5
 6 months...........  18.5
 7 months...........   9
 8 months...........   6.5
 9 months...........   4.3
10 months...........   1.5
11 months...........   1.5
12 months...........   4.7
Not only is the muscle maintained in a state
of rest, but overstretching of muscle and
tendon  is  prevented and  what  is of  equal
importance, contraction and shortening of the
antagonistic muscle  is impossible.
  In our clinic many of the splints employed
were designed by Lieutenant Buerki, others
were  adopted  from  those in use in  other
clinics.  The  sphnts for musculospiral and
external popliteal  paralysis  and  for  cases
recovering from  operation upon  the  sciatic
or pophteal nerves were made after Lieuten-
ant Buerki's designs (see Figs. 4 to 9).  The
sphnt for the median and ulnar paralysis was
fashioned after the  pattern  of that used at
the Walter Reed General  Hospital and that
for the brachial plexus palsies after the splint
used at  General Hospital No. 9. The essential
features of  a serviceable splint are these: it
should  be  comfortable, light in  weight,  not
cumbersome,  of  simple construction,  easily
removed  and retained in position without
bandages.   All the sphnts in our clinic met
these qualifications  and were made  in  the
sphnt room, by unskilled hands, out of heavy
steel  or copper wire.  Especial  emphasis is
laid upon  the avoidance of the bandage in
the apphcation of the sphnt because  splints
must be  removed  daily  when  the  patient
receives massage or while  he is employed in
the curative workshop.
  Physiotherapy.   In all  peripheral  nerve
clinics  the  physiotherapy  department is  re-
garded  as an essential feature of the organiza-
tion  and  serves  a   useful purpose.  While
neither massage  nor electricity can  in  the
smallest degree  prevent  the atrophy of a
muscle  once its nerve supply has been inter-
rupted, manipulation by massage and passive
motion will aid in mobihzing joints that are
restricted  in movement  for  one cause  or 
S                   SURGERY, GYNECOLOGY  AND  OBSTETRICS
              Fig. 4.           .          Fig. 5.                      Fig. 6.
  Fig.  4. Splint for musculospiral paralysis.             Fig. 6. Splint for median paralysis.
  Fig.  5. Splint for ulnar paralysis.

another.  Contraction of the paralyzed mus-   of  peripheral nerve  lesions from so many
cles by electrical  stimulation is  a valuable   angles,  it will be impossible to include in the
substitute for massage, and especially in the   discussion of the technique the many details
operative cases,  it is of untold value from a   as  they affect  the individual  nerves.  The
psychological point  of view, in that during   various steps of the operation will be reviewed
the long and trying period, both before and   as in its wider apphcation and as practiced at
after operation, the patient is content  in the   General Hospital No.  11.  To begin with the
belief that by some magic  influences elec-   incision must extend well above and below the
tricity will restore power to the palsied limb,   lesion.  In the arm it is frequently necessary
  For the recovering cases the curative work-   to make an incision from the axillary fold to
shop plays an important r61e. There  is no   the elbow or below, if the ulnar is to be trans-
doubt that purposeful movements are more   posed.  The nerves must first be exposed and
effective in the restoration of function than   identified well above and below the lesion and
calisthenics, passive movements, or massage,   then traced  as  far as possible through  the
Furthermore the  patient  himself is  much   entanghng scar tissue.  Frequently it is neces-
more  content, his  morale better,  when his   sary to mobilize the nerve for a considerable
time is occupied in some form of occupation   distance above and below the lesion to secure
which maintains his interest.                  approximation after resection.
  Secondary debridement.  In many instances    Instead of towels as wound protectors, we
it was necessary to postpone operation because   have used a sterile sleeve slit the length of the
of unhealed wounds. In many of these there   wound  and  secured over the edges  of  the
was a chronic osteomyehtis.  The postpone-   wound  with Backus forceps.  This enables the
ment of nerve suture for weeks or months was,   position of the  arm to be changed,  as is so
together  with prolonged  suppuration, pre-   often necessary, with  greater facility than if
judicial to the ultimate recover)- of function,   draped with towels.
To hasten the healing of the wound, Captain    The  dissection itself is one  of  the most
King  proposed  a preliminary debridement   tedious of surgical procedures. An abundance
with disinfection of the wound by the Carrel-   of scalpels is necessary since the edge is soon
Dakin technique,  and  when the wound was   blunted by the dense connective tissue. While
sterile, secondary closure,  filling  the  defect   sharp dissection with the  scalpel is to be pre-
if any, with  a fat transplant.  This plan of   ferred in general, we have found a small pair
procedure was put in effect with the happiest   of eye tenotomy scissors convenient in freeing
result and final healing was secured in three   the nerve at the point  it enters the dense scar
or four weeks in wounds which, if  left  to the   tissue where it  is difficult to distinguish be-
natural processes of repair, would have con-   tween  the two  (Fig.  12).  There  are many
tinued unhealed for as many months (Figs. 10   objections to the use of the tourniquet and to
and 11).                                      avoid the necessity  of constant sponging in
  In a paper which touches upon the problems   order to keep the field clear, since oozing is 
FRAZIER: PERIPHERAL  NERVE INJURIES
9
Fig. 7.  Splint for deltoid paralysis.
continuous,  we  have  found  a  continuous
stream  of  normal sahne  solution, directed
precisely at the point of dissection to possess
many advantages.  The constant oozing is an
annoying feature, constant sponging traumat-
izes the  tissues and the continuous play of
solution  upon it keeps the field clear.  When
sponging is necessary, small pledgets of cotton
should be used.
  Electrical stimulation.  Electrical stimula-
tion of nerves on the  operating table may
serve a  twofold  purpose.   Occasionally  the
identification of  individual  nerves in  the
upper arm or of roots or cords of the brachial
plexus is facilitated by the use of the battery.
But more  frequently we  have  found it of
service in deciding whether resection is or is
not appropriate and how  much if  any of a
given nerve may be conserved.  Occasionally
the external appearance of the nerve  might
not justify resection; if faradization of the
nerve  is followed  by a response,  resection
would  be clearly contra-indicated.  If  doubt
still  exists  as  to  the  propriety of   re-
section we have  in  some instances spht the
sheath of the nerve and applied the electrode
directly  to the fasciculi.  By this procedure
we  have been able to  conserve some  fibers
which  otherwise would have been sacrificed.
Apart from the practical value of faradization
Fig. 8 (at left). Splint for external popliteal paralysis.
Fig. 9.  Splint for sciatic paralysis.-
we have been able to make, under the direc-
tion  of Captain Kraus,  interesting observa-
tions as to nerve topography.  For example,
we have found which portions of the circum-
ference of the median nerve are purely sen-
sory and might  be sacrificed where it is de-
sirable to use the median as a receptor for
lateral  implantation suture, as of the ulnar or
musculospiral nerves.
  Further interesting observations have been
made as to the results of nerve stimulation of
the peripheral segment  after the nerve has
been divided preliminary to suture.  In one
instance the musculospiral,  clinically  quite
unreactive to the faradic and showing a
partial reaction  of degeneration (no reaction
of the  nerve  to galvanism and slow contrac-
tion of the muscles without any polar reversal)
gave, on  stimulation  of the distal end  at
operation, a definite response in the extensor
indicis. In another instance the median nerve
was  found divided, but  stimulation of the
peripheral stump gave reactions in the flexors
of the fingers and in the pronator radii teres.
We shall  need pathological  confirmation  of
the absence of connecting fibers in the sur-
rounding tissues.  Another type  of electrical
response has  been the  presence of  faradic
reaction at operation but not clinically, with
no visible discontinuity of the nerve present.
A much stronger current is needed to bring
about these reactions in diseased nerves than
is needed to stimulate a normal nerve.
  Resection.  In  the final analysis the success
or failure  of nerve  suture depends  upon 
IO
SURGERY, GYNECOLOGY  AND  OBSTETRICS
whether  or  not both central  and peripheral
segments contain healthy fasciculi free from
the entanglements of adventitious connective
tissue. The regeneration processes of nature
are so well  performed that  given healthy
fascicuh, regeneration will occur in spite of a
clumsy suture.  Hence all depends upon  the
judgment of the operator as to  how much
tissue is  resected from either segment.  The
inchnation is to resect as httle as possible in
contemplation  of the difficulties in bridging
the defect. But this must be disregarded and
the criterion always must be the appearance
of the nerve  on cross section.  With a safety
razor, section is made at intervals of  2 to 3
millimeters until the appearance of the cross
section is that  of normal fascicuh. It is sur-
prising   how  completely   the  picture  will
change,  when  the sections  are  made  but 2
millimeters  apart,  from one in  which  the
fascicuh  are  embedded in scar tissue to one
in which there appears to be no  scar tissue
at all  (see Fig. 17).  The  variation in  the
number of fascicuh in the central and periph-
eral segments  is usually  very  great; there
may be  8 or 10 in the central segment of a
musculospiral nerve  and only 3 in the periph-
eral segment.  The  actual  resection should
not be begun until all is in readiness for suture.
All bleeding should be controlled, the bed of
the nerve prepared and if stretching is neces-
sary to aid in bridging the defect, this may be
apphed by traction  on the bulbous ends.
  Suture. The final approximation of  the
divided segments may be accomplished alone
*    /*    a   «•     *,    /*
  Fig. 10 (at left). Wound after debridement and Dakin-
izing before suture.
  Fig. 11. Wound after secondary suture.
by  through-and-through  tension  suture or
together with  interrupted sutures  in  the
perineurium. We have employed the latter
technique striving to secure accurate opposi-
tion of  the  sheath in  the behef that by so
doing, the  neuraxes  will  be  directed with
greater  certainty from  the central to  the
peripheral   segment.    One   through-and-
through  chromic catgut suture  is used as a
stay suture  to prevent tension upon the fine
silk perineural sutures and at the same time
Fig. 12.  Instruments used in nerve suture.
  Fig. 13. Battery and electrode used in stimulation of
exposed nerves at operation. 
FRAZIER:  PERIPHERAL NERVE INJURIES
n

*****
Fig. 14.  Method of stimulating nerve exposed at time of operation.
to obhterate the space between the segments.
If perineural  sutures alone  were used  this
space would fill with blood clot which when
organized would offer a barrier to the passage
of the new axis  cyhnders.  Four to six silk
Case No.	Date of Admission
Name	Rank Co. Organ.
General Hosp. 11	Reg. No. Date of Exam
Home Address	Age
DIAGNOSIS	
Electrode Uni — Bi.	
Level of Lesion	Nature of Lesion
Level of Stimulation	Operation
Level of Bifurcation	Operator
Muscles
  Key
 X  0
Result
Black— Cephalad, Caudad, Post., Ant.
White — Cephalad, Caudad, Post., Ant.
Pathological Findings
  Fig. 15.  Chart used in recording findings from electrical
stimulation at operation.
sutures suffice to  secure accurate apposition
of the perineurium.  There are two points in
the technique of suture worthy of attention.
In the first place the stay suture should not be
tied,  when there  is any  tension, until the
perineural sutures are introduced and  tied.
To tie the tension suture first will cause the
fascicuh to protrude on either side and make
it difficult to keep them within the sheath as
the perineural sutures are tied.  This  may
seem  to be a minor matter, but by observing
this precaution a  real difficulty in  nerve
suture will be avoided.  The second point has
to do  with the prevention of rotation in suture
and the preservation of nerve pattern.  Before
the nerve is dissected from its bed guide su-
tures  of silk are introduced at corresponding
points on the circumference  of  central and
peripheral segments (see Fig. 18).  If this pre-
cautionary measure  is  not adopted  the
operator can never be sure that, after the two
segments   have been  freed  a  considerable
distance above and below the lesion, there
will not  be  some  rotation.   Whether  the
avoidance of  rotation  is  of real  or only of
theoretical importance  might  be open to dis-
cussion.  Langley1 is of the belief  that accur-
acy in apposition is one  factor determining
the degree of recovery. By distortion of the
nerve  pattern  the central nerve cells, which
  iBrit.  M. J., 1918, 1,45. 
12
SURGERY,  GYNECOLOGY  AND  OBSTETRICS
Fig. 16.  Shows method of sectioning nerve with safety razor.
formerly controlled only a flexor muscle, may,
after suture and regeneration,  control flexor,
extensor, adductor, abductor or rotator mus-
cles in various proportions.  If  a sensory fila-
ment unites with a motor there may be a
functionless union.  Hence it is concluded
that any procedure which reduces disturbance
of  nerve pattern  will make recovery  more
complete and will shorten the  time taken to
procure that degree of recovery.
  With careful suture of the nerve sheath all
forms of so-called  protection to the hne of
suture are  not  only unnecessary but we be-
lieve undesirable.  Fascia, fat,  the  use of
Cargile  membrane,  increase  rather  than
diminish the tendency  to  connective-tissue
formation.  A suitable nerve bed is desirable
and the best is an intermuscular  plane.  The
old bed of scar tissue or flaps of muscle tissue
are both objectionable.  When a bed in the
normal strata is not  available there is no
objection to transposing  the nerve to  a plane
between the superficial and deep fascia.
  The wound should  be closed  with inter-
rupted sutures, tier by tier, in  muscle, fascia
and skin, as far apart as  possible, so as to
permit of the escape of lymph and serum that
would inevitably accumulate were the sutures
too  close  together.  With this precaution
drainage will be unnecessary.
  In most instances the limb, forearm, or leg
must be retained in a position  of flexion to
relieve tension. This position is  secured by a
lateral plaster-of-Paris sphnt. It has been our
practice to maintain the hmb in the position
in which it was placed at the  time of suture
for from four to six weeks, four  in the upper
and six in the lower extremity.  The limb is
gradually brought into  extension during the
succeeding four  weeks.  Daily massage is
given from the day the sutures  are removed
and galvanism is apphed at the same  time.
  After suture of the  sciatic and pophteal
nerves the plaster-of-Paris sphnt is removed at
the end of the  second week and a light wire
sphnt substituted (see  Fig. 9).  This splint
permits of flexion of the knee  but not of ex-
tension beyond the desired point.  When the
time comes to  begin extension,  this is regu-
lated by daily straightening the sphnt a httle.

                SUMMARY
  While  in this discussion it has  not been
possible to take up the technical details as 
FRAZIER: PERIPHERAL  NERVE  INJURIES
U
Fig. 18.  Steps in technique of nerve suture.
V
S3ULJBL-
•*-


Hr
+I-W
Fig. 17.  Steps in technique of nerve suture.
apphed to individual nerves, a summary is
given in conclusion of  the principles which
have governed us in deahng with the prob-
lems applicable to all.                 "!*,*':*
  1.  Liberation or neurolysis has been given
preference in the  absence  of a  complete
anatomical  division or a  neuroma in con-
tinuity when after excising all scar tissue and
laying  bare the nerve sheath there is a quick
response to faradism.
  2.  Resection and suture are essential when-
ever neurolysis is contra-indicated. Resection
must be carried central  and distalward until
healthy scar-free fascicuh are exposed.
  3.  In bridging defects the nerve transplant
must not be employed until advantage has
been taken of every other reasonable measure:
to wit, nerve stretching, immediate or con-
tinued  (as  with  sutures  through  bulbs),
mobilization,  transposition as  of  ulnar and
musculospiral, and in  exceptional  instances
lateral implantation suture as ulnar or mus-
culospiral into median.
  4.  When these fail  a nerve transplant is
justifiable, the autotransplant being the first
choice,  and  homotransplant  (preserved  in
vasehne, liquid  petrolatum, or 50 per cent
alcohol), the second choice. For  autotrans-
plant the musculocutaneous or sural  nerves 
SURGERY, GYNEC
  Fig. 19. Patient with recovering paralysis of external
popliteal nerve using jig saw for curative purposes.
of the leg, the radial or internal cutaneous of
the arm,  may be  selected on  the basis of
convenience.
  5. In nerve suture it is equally important
to know what one  ought not to do.  In  this
category we include  suture a distance,  the
flap operation, bilateral anastomosis  (as  rec-
ommended by Hofmeister) and  tubuhzation.
  6. Sharp clean dissection, careful haemo-
AND OBSTETRICS
  Fig. 20.  Handle of saw made to fit paralyzed hand by
means of modeling compound.

stasis,  the approximation of healthy fasciculi,
without  undue tension,  represent the tripod
upon  which  the success of  nerve  suture
rests.
  7. Tendon transplantation should be  em-
ployed when suture fails and is particularly
appropriate in residual palsies of the posterior
interosseous, with inability  to  extend wrist
or fingers,  and anterior tibial palsies  with
resulting foot drop.
  8. The after-treatment should include (a)
enforced fixation for a period of 4 to 6 weeks
with gradual  straightening of  the hmb, (b)
massage  and galvanism until voluntary move-
ment returns,  (c) exercises varied according
to the muscles involved and with a view of
sustaining  the interest  of the patient.