[Extracted from the American Journal of the Medical Sciences for July, 1874.] 
TRAUMATIC NEURALGIA; 
SECTION OF MEDIAN NERYE. 
S. WEIR MITCHELL, M.D., 
MEMBER OF THE NATIONAL ACADEMY OF SCIENCES, 
[WITH FIVE WOOD-CUTS.] 
Miss T. at the age of two and a half years ran a splinter into the 
palm of the right hand over the point at which the median nerve divides 
in order to send branches to the thumb and fingers. The fragment, which 
came from a barrel hoop, was said to have been, when it entered, a third 
larger than when taken away twenty years after. It passed so deeply 
into the hand that it was thought best to poultice the part and encourage 
suppuration before removing the foreign body. To the physician’s surprise 
the wound healed rapidly, every sign of irritation passed away, and the 
child soon after was taken from this city, in which the accident took place. 
The piece of wood could always be felt distinctly in the palm, but 
only once, when in Panama, at the age of twelve, was its presence in the 
least degree annoying. When 22 years old, Miss T., then in Naples, 
caught hastily the falling top of a trunk, and in so doing bruised the 
region in which lay the splinter. Great local pain and slight swelling 
followed, but, growing better in a few days, left her with some uneasiness 
and discomfort in the part struck. After three months she began to have 
pain in the right shoulder, for which Dr. Suchet, of Paris, ordered lini- 
ments, regarding it as rheumatic. In May of the same spring of 1871, 
the pain in the hand grew worse, and in July it was severe in the median 
palm, thumb, and palmar face of the index-finger. At Plombieres, in 
August, and later while travelling, it increased, and extending to the fore- 
arm assumed throughout a hypenesthetic character, so that she began to 
guard the parts from foreign touch. It now became plain that the trouble 
was due to the splinter, and accordingly, at Milan, October 22, 1871, Dr. 
Sapoliui, Surgeon to the King of Italy, assisted by Dr. Guerini, after a 
careful search removed the splinter, which is said to have lessened in 
size, is certainly smoother than it could have been at first when twenty 
years before it entered her palm. Dr. Sapolini, whom I had the pleasure 
to meet in Milan last summer, told me that it lay among the diverging 
median nerve filaments, and was taken away with difficulty. On 
awaking from the chloroform sleep, she was at onqe conscious of intense 
1 2 
pain in the fore-finger and thumb. Within a few days the fingers con- 
tracted in firm flexion, the pain became exquisite, a touch was torture, and 
the median palm from time to time swelled and throbbed so as to induce 
the belief that pus had formed. Under poultices it would, however, sub- 
side, and in a few days go through the same process anew. The wound 
healed in a month, but thenceforward she lived under the influence of mor- 
phia, being almost entirely sleepless from the incessant pain and exquisite 
hyperalgesia which made the lightest contact a thing to be guarded against 
by precautions which seemed almost absurd. Despite the pain, a success- 
ful effort was made to straighten the fingers by the aid of a dorsal splint, 
and on its removal they remained straight or extended. The torment was 
worst on the thumb, median half of face of forefinger, the annulus, and the 
median palm close to the forefinger. It also extended on to the back of 
the hand, where it affected the dorsal surface on the radial side of the hand, 
and especially the last two phalanges of the second and third digits where 
the pain was no less than in front. Throughout all the regions named it 
was a constant burning pain, with red and smooth surfaces upon which 
the fall of a bit of lace or a veil edge was simply anguish. 
In this condition Miss T. went from one well-known physician to 
another, the pain passing up the forearm and involving its whole surface 
in a hyperalgesia which varied in degree and was accompanied with a dis- 
turbance of the local circulation in the limb, so that it was now intensely 
flushed and now pale in spots. The shoulder also continued to be painful, 
and associated neuralgias awoke in the right face and neck and even in 
the right foot. 
The whole range of usual local and general therapeutic means failed to 
lessen her pain, although heat, cold, actual cautery, Yienna paste, hypo- 
dermic injections of morphia, blisters, electricity (induced currents) were 
employed in turn, with an endless list of others which I need not 
catalogue. At length, in November, 1871, Dr. Sapolini found, after the 
most careful study, that, while protracted pressure on the median nerve 
in the forearm caused only an increase of pain, pressure on the musculo- 
spiral, at first increased and by and by destroyed not only the pain 
but the sensitiveness so completely that the finger and thumb could be 
roughly handled both on their dorsal and palmar faces. Again and 
again he applied this test, and when fully convinced that he was not mis- 
taken and that relief always followed the pressure, he cut down on the 
musculo-spiral nerve above the outer side of the elbow and removed an 
inch of it. Absolute ease at once followed this section, pain and sensi- 
tiveness alike disappearing, while, to the amazement of the skilful ana- 
tomist who operated, the loss of touch in the radial regions of the back 
of the hand was so slight that he doubted there being any loss, although 
a considerable amount of wasting in the extensors and an absolute wrist- 
drop showed that the muscular distribution of the nerve had suffered. The 
full extent of this loss I have not learned. It left for a time a hollow in 
the forearm, but within a few months (four or five) the arm regained its 
plumpness, and as to the lack of power in the extensors it was certainly 
slight in the spring of 1873, although at this time the pain was enough 
to so far inhibit movement as to make it no easy task to judge of the real 
amount of motility. As to the sense of touch being but slightly hurt 
anywhere in the hand by the section of the musculo-spiral, I have also 
the assurance of Miss T., whose curiosity led her to examine the part 
with care. 
On the eighth day after the operation the pain suddenly returned. The 3 
sensitiveness to touch remained somewhat lessened on the back of the 
fingers and thumb, and on the whole the torture was thereafter less 
extreme, but it was still terrible, and the associated sensations grew worse, 
so that, as I have many times seen in other cases, the whole skin grew 
irritable and the sources of torment multiplying, bright lights and sharp 
sounds increased the pain, sensitive spots were developed on the scalp, a 
thick crop of herpetic eruptions covered the right arm, neck, and face, 
while the general health began to fail despite the most careful and skilful 
efforts to sustain it. Something was due no doubt to the prolonged heal- 
ing of the wound, which was interfered with by frequent abscesses, and at 
last at the third week by erysipelas. 
After the failure to gain full relief from Dr, Sapolini’s well-considered 
operation, Miss T. consulted very many surgeons and physicians of dis- 
tinction, but without obtaining any further good result. In August, 1872, 
after using by Sir James Paget’s direction a long series of hot water arm- 
baths, Miss. T., by his advice, returned to America. In January, 1873, I 
saw her in New York, and in the middle of February she placed herself 
under ray care in Philadelphia, where, with the kind aid of my friend Dr. 
Wm. W. Keen, I made the following notes of her case. 
At this time, with no notable functional trouble, Miss T. was thin and 
weak and singularly liable to sudden flushes or as sudden pallor. She 
slept with the hand propped upon its ulnar edge, and awakened many 
times at night when it fell over or was touched by the bedclothes, while all 
day long she devoted herself to the task of shielding the part from every 
foreign contact. This anxiety to avoid having the hand touched, and the 
constant influence of pain, gave to her physiognomy a singular expression 
of suffering and vigilance, such as I have rarely seen since the terrible 
traumatic neuralgias of the late war. 
The arm presented numerous marks due to the use of cauteries, and on 
the palm at the edge of the thenar eminence was the scar of the opera- 
tion for removal of the splinter, and above the elbow was the cicatrix left 
by that of the nerve section. 
Motilily.—Miss T. can use the deltoid, and flex and extend the arm, 
but, if the movement be sudden or extreme, it causes pain in the shoulder 
and neck. She can slowly and with pain pronate and supinate the fore- 
arm. She cannot extend the wrist, but on its being extended can delay 
its fall, chiefly by using the radial extensors. Slight power to flex wrist. 
The first and second fingers have no motility; but she can stir the last 
joints of the other fingers in flexion and extension. Probably most of 
this lack of power is due to long disuse and the inhibitory power of con- 
stant pain. The future history proved this view to have been correct. 
Sensation.—This was examined by nerve regions. Touch and power to 
localize or place a touch are normal in the musculo-cutaneous distribution. 
Touch is well felt above scar left over the point of section of the musculo- 
spinal. Touch just below the scar is badly felt, and is referred above the 
scar. The radial and median sensation in the arm is normal, as well as that 
of the internal cutaneous nerve. In the radial area on the back of the thumb 
and first and second fingers touch is referred correctly, and is everywhere 
felt; but thoughout this region every touch is felt as lioth touch and pain. 
In a less degree this is true of certain parts of the whole arm, and most 
notably of parts just around the scar of the operation on the musculo-spiral. 
The ulnar territory is in all respects healthy by compass points. The sen- 
sitiveness of the thenar eminence is not acute, but increases as we approach 
the index-finger. The hyperalgesia is exquisite in the face of the second 4 
finger, and the radial side of the third finger; on the face of the thumb 
and the palm ; over the first joint of the index. In these regions touch 
is so much more distinctively felt as pain that the degree of health of the 
power of touch cannot be thoroughly studied. The over-sensitiveness is 
worst in parts of the median and radial territory of the hand, better in the 
external cutaneous branches of the musculo-spiral, and normal in the ulnar 
and internal cutaneous. 
The great nerve tracks are tender upon deep pressure, which, over the 
median and musculo-spiral above the scar, causes increased pain in the hand. 
The axillary and brachial plexus are also tender, as well as the three upper 
cervical vertebrae. At times the surface of the right chest is sore, and 
also the teeth of the right side of both jaws, the teeth being themselves 
sound. 
Secretions.—The median palm sweats incessantly, and the odour of the 
perspiration is very acid and heavy. 
Nutrition.—The measurements of the two arms are as follows : 
Left forearm 8| inches 
Right “ 8 “ 
Left arm biceps . . . , . . . 9| “ 
Right “ 8 “ 
There is at this date no especial wasting of any of the forearm mus- 
cles, and no remarkable want of muscular tone. The interosseal groups 
are not wasted. 
The two little finger nails are normal and alike, the second finger and 
thumb nails on the right hand are curved laterally, that is, singularly 
arched. The right index nail is inch broad, that of the left inch. 
She thinks there has been no difference in the rate of growth. The gene- 
ral tint of the right hand is livid, and the arm is liable to sudden alterna- 
tions of feeling as to temperature, while the slightest irritation causes at first 
intense paleness followed by definitely limited islands of deeply flushed 
skin. The skin of the thumb and index-finger is rough, ragged, and 
marked with yellowish patches of loosened epithelium. 
Temperature.—l made, at this time, an effort to ascertain the tempe- 
rature of the affected parts, but totally failed, owing to the sensitiveness 
of the surface being such as to forbid the mere touch of the instruments. 
Galvanism.—The forearm and hand muscles all reacted rather feebly 
under induced currents, but this was possibly due in some degree to long 
inaction, and she could not endure a severe use of the battery. The effects 
of galvanism were most interesting, and such as at first to induce me to 
believe that the constant current might prove of curative value. A cur- 
rent of at least ten cells in either direction along the track of the median 
nerve rendered the fingers nearly altogether free from over-sensitiveness, 
and enabled me, while the current passed, to ascertain that the sense of 
touch in these parts was but slightly impaired.' This experiment was made 
again and again with the same result, and satisfied me that the nerve could 
not be very gravely altered. I arn not aware of any like observation else- 
where recorded. I may add that the influence was limited to the median, 
and that continued galvanic treatment failed to relieve, except at the mo- 
ment, and this is in accordance with all my former experience of traumatic 
neuralgia. 
A long and careful study at last satisfied me that the cause of trouble 
lay in the disordered filaments of the median nerve in the hand, and that 
the effects exterior to this part were probably due to disturbances of the 
sensorium, propagated from the hand and resulting in associated neuralgias, 5 
such as are commonly but inaptly termed reflex. One question remained 
to be answered, How far up the median nerve had the organic changes 
travelled. To this I could give no positive reply, since the whole nerve 
was tender, and there might possibly be a sclerotic condition of the entire 
nerve up to its spinal origin ; but in this case I should have expected to 
find the muscles less sensitive to induced currents and the tactile sense 
greatly disturbed, which was not the case; I therefore determined to take 
the risk and divide the median nerve. At this stage Dr. Brinton saw 
the case, and, in consultation with Dr. Keen, we determined to operate 
on the forearm below the point at which the motor filaments are given off 
to the forearm muscles. The only loss would thus be the sensibility 
of the median territory in the hand and the mobility of certain thumb and 
interosseal muscles. I add here Dr. Brinton’s account of the operation, 
which was done by him with the assistance of Drs. W. W. Keen and 
Wharton Sinkler. 
“March 2d, 1873, I first ascertained precisely the margins of the flexor 
carpi radialis and palmaris longus muscles by extending the hand upon the 
forearm. I then made an oblique incision inches long, from over the border 
of the first to that of the last-named muscle; the lower end of this incision 
terminated two inches above the line of the wrist-joint. 
“ The superficial fascia and the muscular aponeurosis were next divided on 
a director in the line of the cut. The tendinous edge of the radial flexor and 
the narrow tendon of the palmaris were thus exposed to view. I then sought 
for the median nerve in the inter-muscular space, and uncovered it at the lower 
end of the cut, just at the point at which it emerges from beneath the oblique 
fleshy fibres of the flexor sublimis digitorum; with the end of the finger this 
muscle was then raised from its bed (without laceration of its fibres) as high 
as the upper end of the incision. The median nerve was thus completely ex- 
posed for an extent of 2j- inches. 
“ It was decided by Dr. Mitchell that the removal of three-quarters of an 
inch of the nerve would be sufficient for the object of the operation; and this 
length of nerve was accordingly excised with the scissors. It was at the same 
time suggested, that, to diminish the probabilities of reunion of the divided 
nerve ends by fresh nerve development, the lower exposed end of the nerve 
trunks should be turned in a transverse direction into the surrounding tissues 
and there fixed. This was accordingly done, the nerve end being retained in 
its new position by a wire suture, which was removed at the expiration of forty- 
eight hours. 
“The portion of nerve thus excised commenced below the origin of the 
muscular and anterior interosseous branches, and terminated above the origin 
of the palmar cutaneous branch. There was no bleeding; and no ligatures 
were required. The wound healed in about ten days.” 
The nerve ends retracted at once to such an extent that, although but 
three-quarters of an inch were taken away, the separation was found to 
be an inch and a half, and this became fully two inches and a quarter, 
when, at my suggestion, the lower end of the nerve was doubled on itself. 
The nerve looked healthy.; and the piece put in Muller’s fluid was studied 
within a few hours by Dr. Bertolet, whose statement I append. A hypo- 
dermic injection of morphia was given ; this drug caused alarming pros- 
tration, while chloral produced the wildest excitement. The wound was 
painful; and on the third day, in this, as in Dr. Sapoliui’s operation, 6 
erysipelas came on. It involved the lips of the wound first and thence 
journeyed to the finger tips and up the arm and over the right side of the 
chest. During this period of eight days I tried and gave up in turn many 
forms of narcotics. From this time the case progressed favourably, need- 
ing no treatment save tonics and a bountiful diet. A few hours after the 
operation I made an examination of the limb as well as the pain in it 
permitted, and found that the palmar face of the thumb and index were 
insensible, and could be touched without any annoyance, but hyperoesthesia 
still existed in the radial territory. On the sixth day there were acute 
pains in the index and thumb, due, I suppose, to the changes in the cen- 
tric end of the cut nerve. On the sixteenth the hand and arm admitted 
of a careful study, and we found the following condition : 
Motion.—The relief from pain enabled her to move all the muscles save 
those damaged by the section of the nerve. The flexor tendons tied fast 
by the cicatrization of the wound, yielded to carefully conducted passive 
motion, and we shortly learned that the extensors and flexors were in nearly 
equally good order, but that in the thumb and index there were subacute 
joint lesions, which promised for a time to limit the range of motion. 
The section of the median nerve disturbed no muscles save those of the 
thenar eminence and the median interosseal groups ; but as one of the 
short adductors of the thumb is fed by the ulnar nerve, there yet remained 
the power to approximate the thumb and fingers 
Sensation was absolutely lost for touch and pain on the palmar face 
of the thumb, index, and up to an irregular line on the radial side of the 
centre of the same face of the third finger. It was not lost on the palm 
though slightly lessened, but was absent on a part of the dorsal ends of 
the second and third fingers. Beyond these regions, as I shall further 
describe, touch was dulled over a much wider range. The area of abso- 
lute loss of feeling is seen at a glance in the accompanying diagram. It 
was traced again and again with the most sedulous care, and each time 
recorded on diagrams which were found to agree. With no less care I 
studied the sensory condition of the radial region. At first it presented 
the hypersesthesia which had never left it since eight days after the opera- 
tion on the musculo-spiral, but from the date of section of the median 
this very rapidly lessened, and within a month was but trifling. The 
sense of touch in this region was perfect. 
The associated neuralgias and the tenderness of the nerves faded with 
equal rapidity, and thus within ten days, except the relics of radial sensi- 
tiveness, there was absolute freedom from every form of pain. 
Nutrition.—The aeneous eruption passed away with the pain, and a 
marked and steady change for the better took place in the colour and vas- 
cular state of the limb. 
All the nails of both hands were stained on the day of the nerve section. 
Those of the left grew steadily at the rate of about 1 mm. a week. None 
of the nails on the right hand grew until the 14th day, when all grew at 
equal rates. 
Temperature.—The sensitiveness before the operation, and the erysipelas 
after it, unfortunately interfered with my earlier thermal studies. 
14th day. No erysipelas, wound healed. 
10 A.M. Right median region 96.5 
Left “ “ 91.5 
9 P.M. Right “ 96.4 
Left “ “ 92.5 7 
16th day. Erysipelas again appeared on the right shoulder, but faded 
in two or three days after a fevered and restless night. 
Right median thumb 92.4 
19th day. Patient well. 
Left “ “ 95.3 
5 P.M. on Ist joint of index ; Eight median nerve region . 97.6 
Left “ “ “ . 94. 
23d day. 
Ball of thumb ; Right median nerve region. . . .93 
Left “ “ “ .... 92 
Right index 93.5 
Left “ 90 
A few days later I awakened a subacute arthritis in the metacarpo- 
phalangeal articulation of the right forefinger by making too extreme 
movement. The trouble proved obstinate, and exacted long rest on a 
splint with repeated counter-irritation by strong solutions of nitrate of 
silver; but this was the sole drawback, and ever since the hand has con- 
tinued to improve in motion, while there remains the most absolute 
freedom from pain. 
On the 20th Nov. 1873, ten months after the operation, Miss T. came 
to Philadelphia again, and gave me a chance to study the peculiarities of 
her condition at this time. 
The forearm muscles all responded readily to moderate faradic currents. 
The essential thumb muscles in the thenar eminence moved under no form 
of electric stimulus, faradic or galvanic, save the short ulnar adductor, 
which being fed by the ulnar nerve responded to both currents. The ulnar 
interossei acted well; the median hand muscles of like groups did not 
respond to any electric irritation. 
Sensation.—The study of the sensations proved very interesting. I 
give the simple details, reserving ray comments. 
The diagrams of lost touch and pain, made within a month after the 
section, remain much the same, except that on the median side of the 
third finger, first and half of second phalanx, touch can now be dully felt. 
The area of the palm in which touch was marked as lessened, is much as 
at that date; perhaps has somewhat bettered. 
The dorsal regions of lost pain and touch remain as in the diagram, 
except that on the outside of the thumb there seems to have been some gain. 
The ulnar half of the third finger palmar face feels light touch through- 
out, and correctly refers it, but is incapable of discerning as two the com- 
pass points at any distance apart. To my surprise the radial half of 
the fourth finger, though feeling a touch everywhere, is also unable to 
discern compass points as two at any distance apart. The ulnar side of 
the palmar face of this finger is more sensitive near the end ; last phalanx 
the points are felt as two at |of an inch apart; on the sound side as two 
at |of an inch asunder. The fifth finger gives the same response on both 
sides of the body, but the patient insists that there is a difference in feel- 
ing in favour of the sound side. 
There is absolute freedom from pain. 
The nails grow alike. The thumb muscles are atrophied. 
Remarks.—The trouble in this case began when the point where the 
splinter lay was struck. It is difficult to say what was the nature of the 
process then set up, but it was certainly irritative in character, and was 8 
suddenly made worse by the operation in which the foreign body was re- 
moved, The hypersesthesia and burning pain, and the contraction of the 
fingers make it probable that the trouble was inflammatory. The after- 
consequences were most interesting and instructive. The phenomena of 
pain and hyperalgesia, at first limited to the median nerve, as usual began 
to bring about in the sensorium a state of morbid irritability in closely 
related groups of ganglionic nerve cells, so that the musculo-spiral was 
next alfected, and this, as I have said, through the sensorium ; next other 
centres felt the same influence, and the irritative radiations inward from 
the diseased median so morbidly altered other and remoter sensation cen- 
tres, as to cause these also to express pain, and thus to give rise to associ- 
ated neuralgias of the shoulder, neck, face, and leg, the influence being 
throughout purely unilateral. When the nerve was divided, the centres 
were at once relieved from this steady afflux of morbid impressions, and 
rapidly regained their healthy states, with the exception of those from 
which arises the musculo-spiral nerve, the radial filaments of which still 
remain slightly over-sensitive, but are also improving. 
In many cases I have traced these associated sensations to a passage 
upwards of the condition of neuritis or sclerosis, which came at last to 
invade other nerves of the parent plexus. At present, I believe that I 
should incline to charge a greater number of these secondary neuralgic 
and other changes to this singular condition of the centres of sensation, 
which, under the influence of constant irritation, propagates, from one set 
of ganglia to another, a growing tendency to evolve pain and other phe- 
nomena in the nutritive sphere. We have thus developed at last in the 
sensory centres a state which elsewhere I have described as being the exact 
analogue of what strychnia causes in the motor centres. Given such a 
state of things, and the sensory centres not only feel as pain influences 
which are not usually productive of pain, but also within themselves origi- 
nate, as it were spontaneously without new irritations from without, the 
condition called pain. As yet we know of no drug which can bring 
about this state of the sensory ganglia, as strychnia causes a like state of 
the motor organs. 
The ease for a time given in all the nerve regions involved by Dr. Sapo- 
lini’s section of the musculo-spiral must, as I think, have been due to some 
influence which it exerted on and through the related groups of nerve cen- 
tres. 
In facial neuralgias not traumatic, I have frequently observed that the 
fits of pain in the infra-orbital could be temporarily bettered or checked by 
pressing upon the supra-orbital, or that pain in the infra-maxillary could 
be controlled by hard pressure on the supra-orbital. Sometimes, as I saw 
to-day in a neuralgia of the jaw in a toothless man, the slightest pressure 
anywhere on the gum will relieve the pain which talking or swallowing 
evolves. A sudden impression thus made at any point more remote might 9 
effect a like object. Thus, lam sure that I have seen pain in the brow 
disappear for days on the removal of a sound tooth, which was not really 
the agent in creating the pain, and I am disposed to explain thus many 
of the reliefs or cures of neuralgia by pulling teeth. 
Section of the musculo-spiral is said, by Dr. Sapolini, not to have de- 
stroyed the sense of touch or pain anywhere in the radial territory of the 
hand, and if the patient and the operator were not deceived, this is to be 
attributed to the remarkable manner in which the nerves run over into the 
territories of their neighbours, and possibly to some variation in the nor- 
mal supply. The part in question remained unaffected as to feeling by 
section of the median, so that the repair made ad interim must have been 
very complete. 
The usual muscular distribution of the radial to the extensors certainly 
suffered, but as there is to-day full power, and as the early and marked 
atrophy has passed away, I conclude that the lost inch of the musculo- 
spiral has been restored most remarkably. Errors as to sensation may 
readily be made, but surely none could be as to the palsy and atrophy of 
the extensors, while also it is well to remember, that although the hand 
nerves run over, as it were, into one another’s territories, the muscles are 
more constantly supplied by single nerves, and have a far less irregular 
distribution. 
In studying the areas of lost sensation in this most valuable case, I shall 
first consider the case of touch. Fourteen days after the operation it was 
as shown in Diagrams 1 and 2. In November, 1813, it had changed but 
Fig. 1. 
Fig. 2. 
a. Pain and touch lost. B. Touch lessened. S'. Touch slightly lessened 10 
little on the dorsal aspect, while on the palmar face it had altered some- 
what, so that, in certain portions of the thumb and third finger, a touch 
was felt in November where in February it was not. 
Perhaps it may be said that the local shock may have been the partial 
cause of the more complete loss in February, but the change was slight. 
Something may be due to the greater attention paid to the region of dulled 
sensation, owing to which the sensorium became trained up to the percep- 
tion of impressions which at a former period could not be felt at all. The 
loss of touch and pain was entire in the regions marked. 
In a part of the palm, as indicated, pain was not notably less, and touch 
was slightly lessened, as measured by compass, for in all of the palm 
marked B, the lightest impact was felt. So also of the touch in the third 
digit, ulnar side, and all of the face of the fourth. These facts are of 
interest because the region of the greatest loss, dorsal and palmar, by no 
means corresponds to the anatomical descriptions and drawings, which 
either allow us to suppose the distribution to be symmetrica], or delineate 
it in diagrammatic lines which do not correspond either to the results in 
this case or in others. The innervation beyond the radial side of the 
third finger is also seen to be disproportionately small. 
In Miss T.’s case there is, too, some loss of function in the ulnar side of 
the fourth finger for which we are hardly prepared by the usual descriptions. 
I had hoped to learn, from this case, whether nail growth is checked by 
nerve section. Unluckily the facts prove too much, since neither in the 
ulnar, radial, nor median territories did they grow for some time. More- 
over, the presence of erysipelas may have influenced the nail growth. 
As to thermal conditions, the laboratory and the clinic have seemed to be 
at variance. In ray recent book I pointed out the fact that the physiological 
nerve-sections show a rise of temperature, and that the surgical sections 
show a fall. I also stated that this was probably due to the surgeon’s not 
having made early studies of temperature and to those of the laboratory 
having immediately followed nerve division. I ventured to predict that 
the heat would be found to rise after clinical section, and to fall when some 
weeks had elapsed. This was the case in Miss T., although in the text I 
have not stated the latter fact. The heat rose remarkably, and continued 
high with some variations for a month. When I saw her anew, after ten 
months, it had fallen in the thumb and forefinger two degrees below the 
temperature of the sound side. 
I append the notes of microscopic appearances kindly made for me by 
Dr. Bertolet. 
Macroscopically, the excised portion of median nerve did not present any 
alterations beyond the loss of the usual pearly-white or glistening appearance. 
The connective tissue surrounding the nerve did not seem to the naked eye to 
be materially increased or hardened, the nerve-cord remainingssoft and pliable. 
The nerve was hardened for section by being allowed to remain for several 11 
weeks in a dilute solution of chromic acid. The whole nerve was then im- 
bedded in wax, and transverse cuts made; these were then stained in Tiersch’s 
neutral carmine solution; the water was then abstracted by placing the cuts 
successively in alcohol and absolute alcohol. They were finally rendered 
transparent in the oil of cloves, and permanently mounted in Damar varnish. 
For the sake of comparison and in order that the description of the altera- 
tions presented might be readily understood, we have given in Fig. 3 the micro- 
Fig. 3, 
Cross-cut of Fasciculi of a Normal Radial Nerve.—a. Dark spot representing the axis- 
cylinder surrounded by the hyaline mass or white substance of Schwann, b. Medullary 
sheath or membrane of Schwann, s. Sheaths of the secondary fasciculi. /. Trabeculae 
of connective tissue subdividing the fasciculus, c. Loose connective tissues in which are 
seen, v, sections of the bloodvessels. 
scopic appearances presented by a normal radial nerve in the cross-cut when 
prepared precisely by the same method. In the cross-section each individual 
nerve-fibre exhibits an external ring with double contour, the cut edge of the me- 
dullary sheath, nearly in the centre of each circle is seen a dark spot, which is 
readily stained by carmine; this constitutes the axis-cylinder. The space between 
the axis-cylinder and the outer circle is filled up with a hyaline mass, known as 
myeline or the white substance of Schwann. Septa of connective tissue, as 
shown in the figure, stretch inwards from the investing sheath or neurilemma 
of the nerve-trunk and divide it into a greater or less number of secondary 
nerve-bundles or fasciculi. In the cross-section these septa are seen as thick 
rings, which are united among themselves by more or less loose connective 
tissue c; in the latter are seen coursing the bloodvessels supplying the nerve d. 
The fasciculi are further subdivided by delicate fibres or trabeculae of connec- 
tive tissue which spring from the sheaths of the secondary fasciculi. 
Fig. 4 represents the microscopic appearances presented by the cross-cut 
of the excised median nerve; the same magnifying powers (180 diameters) 
being employed as in the preceding figure. It will be seen that the connective 
tissue of the sheathing of the fasciculi as well as the interfascicular trabeculae 
are slightly increased in thickness and quantity, though not to that degree 
which marks the hypertrophy attending chronic neuritis. The sheaths of the 
fasciculi have no longer the distinct fibrillated appearance of the first prepa- 12 
ration, but merge into the connective tissue in the vacuity. The individual 
nerve-fibres themselves, however, present the principal changes. In very few 
of the rings of the secondary fasciculi, even with the higher powers (vide Fig. 5), 
Fig, 4. 
Fig. 5. 
Figs. 4 and 5. Cross-cut of Fasciculi of the Median Nerve, exhibiting the Lesions of 
the Wallerian Degeneration.—a. Confused outlines of the nerve-fibres, concentric arrange- 
ment within the circles ; scarcely any axis-cylinder to be seen, s Sheaths of the fasciculi. 
/. Trabeculae of connective tissue, moderately thickened, v. Bloodvessels, unaltered. 
can the axis-cylinder be satisfactorily recognized, nor is it stained by the 
carmine. The circles of the individual nerve-fibres are no longer clearly de- fined; they are seen as a confused mass of concentric rings. The myeline is 
more highly refractive than usual; fresh sections of the nerve, made shortly 
after its removal, afford a decided play of colours under the polariscope; this 
property, however, has been destroyed by the process of hardening and mount- 
ing employed. Longitudinal sections of the altered nerve revealed a slight 
increase of the nuclei in the sheaths of Schwann ; the latter were no longer 
homogeneous, but granular and coarsely striated. 
The lesions presented in this specimen are those known as Wallerian degene- 
ration ; the disintegration and atrophy occurring primarily in the nerve-fibres 
themselves, while in chronic hyperplastic neuritis the disintegration and atro- 
phy result from the pathological changes occurring primarily in connective 
tissue framework supporting the nerve-fibres.