INJURIES OF NERVES 
AND THEIR CONSEQUENCES. 
BY 
S. WEIR MITCHELL, M.D., 
Member of the National Academy of Sciences; 
Fellow of the Philadelphia College of Physicians ; Physician to the Philadelphia 
Orthopedic Hospital and Infirmary for Diseases of the 
Nervous System, etc. 
“Ihold every man a debtor to his profession; from the which as men of course do seek to receive 
countenance and profit, so ought they of duty to endeavor themselves, by way of amends, to be a help 
and ornament thereunto."—Bacox. 
PHILADELPHIA: 
J. B. LIPPINCOTT & CO 
187 2. Entered, according to Act of Congress, in the year 1872, by 
In the Office of the Librarian of Congress at Washington. 
J. B. LIPPINCOTT & CO., TO 
w:mi. imt.zd., 
PROFESSOR OF DISEASES OF THE MIND AND NERVOUS SYSTEM 
AND OP 
CLINICAL MEDICINE 
BELLEVUE HOSPITAL MEDICAL COLLEGE, NEW YORK; 
IN THE 
Whose liberal views created the special hospital which furnished the chief 
experience of this volume; with admiration of his high qualities 
as physician and scholar, and with grateful memories of 
a long and constant friendship, I dedicate the 
following pages. PREFACE. 
In the following pages I have endeavored to present 
in as concise a form as possible the history of lesions of 
nerve tranks and their consequences. While I have not 
hesitated to use the observations of others, the work is 
chiefly based upon my own experience. 
I am largely indebted for assistance to Drs. George 
Morehouse and W. W. Keen, my former colleagues at 
the U. S. A. Hospital for Injuries and Diseases of the 
Nervous System, and I am also under many obligations 
to Dr. Tyson. 
1332 Walnut Street, Philadelphia, 
S. WEIR MITCHELL. 
February, 1872. 
(V) CONTENTS. 
CHAPTER I. 
Introductory 9 
?AGE 
CHAPTER II. 
Anatomy of Nerves 13 
CHAPTER III. 
Neuro-Physiology .......... 30 
CHAPTER IV. 
Physiological Pathology of Nerve Lesions 56 
Varieties of Mechanical Injuries of Nerves 82 
CHAPTER V. 
CHAPTER VI. 
Symptomatology of Nerve Lesions 135 
CHAPTER VII. 
Remote Symptoms 147 
CHAPTER Till. 
Sensory Lesions 179 
(vii) CONTENTS. 
CHAPTER IX. 
PAGE 
Diagnosis and Prognosis of Injuries of Nerves .... 215 
CHAPTER X. 
Treatment ............ 229 
CHAPTER XI. 
Treatment—Continued .... .... 244 
CHAPTER XII. 
Treatment—Continued 282 
CHAPTER XIII. 
Lesions of Special Nerves 318 
CHAPTER XIY. 
Neural Maladies of Stumps 342 INJURIES OF NERVES. 
CHAPTER I. 
INTRODUCTORY. 
English medical literature contains no complete trea- 
tise on injuries of nerves and the diseases consequent upon 
them. In fact, few persons have at any time in medical 
history been so situated as to command the peculiar 
opportunity which has fallen to the lot of the writer of 
these pages, and which alone he feels may justify him 
in adding another to the numerous monographs which 
to-day claim the attention of the profession. 
In May, 1863, Dr. Wm. A, Hammond, then Surgeon- 
General of the U. S. Army, requested me to share with 
Dr. George Morehouse the medical charge of an army 
hospital for nervous diseases, the foundation of which I 
had suggested to the medical bureau, over which at that 
time Dr. Hammond presided with such ability as has 
caused his name to be inseparably associated with the 
medical and surgical history of the late civil war.* 
* When this hospital was organized, I urged upon the Surgeon-General 
the necessity of freeing its medical statf from the usual administrative 
duties which take up so much of the time of our military hospital 
surgeons. Arrangements were therefore made which permitted us to 
devote to our cases all available time, and left the government of the 
house in charge of a competent surgeon-in-chief. I may be permitted 
to add, that when Dr. Hammond left office he had established special 
wards or hospitals for diseases of the eye, for syphilis, for stumps, for 
9 10 
INJURIES OF NERVES. 
This hospital promised very early to surpass in useful- 
ness the fondest expectations of its founder and of the 
staff, to which, at my request, Dr. W. W. Keen was added, 
as resident surgeon. 
It was finally enlarged to 400 beds, and removed 
from Christian Street, Philadelphia, to Turner’s Lane, 
in the suburbs of the city, where, for the first time, its 
capacity enabled us to classify in distinct wards the 
numerous cases which fell under our care. Never has 
such an opportunity for the study of nerve lesions and 
their results presented itself. A multitude of cases, re- 
presenting almost every conceivable type of obscure 
nervous disease, was sent to us from this department 
and that of Washington, by surgeons who felt con- 
scious that these forms of disease were rarely amenable 
to treatment in wards crowded with grave wounds, 
constantly demanding all the time and care of over- 
worked attendants. The medical inspectors, and espe- 
cially Dr. John Le Conte, were active in selecting and 
forwarding such instances of disease as seemed to them 
suited to our service: so that we received and treated 
during two years an enormous number of cases of dis- 
eases and injuries of the nervous system. 
Among these was a vast collection of wounds and 
contusions of nerves, including all the rarest forms of 
nerve lesion of almost every great nerve in the human 
body. Nor was this mass of material neglected in any 
point of view. New modes of treatment were devised, 
and gymnastic classes instituted, under the care of in- 
telligent sergeants of the invalid corps; electricity was 
constantly employed, and hypodermic medication — at 
diseases of the heart and lungs, and was maturing a plan for the further 
extension of this system, with such arrangements as must have resulted 
in vast advantages to scientific medicine and surgery. INTRODUCTORY. 
11 
that time somewhat novel—was habitually resorted to, 
and its effects carefully studied. 
The Surgeon-General and the hospital staff equally 
felt that besides the benefit to the sick soldiers, in thus 
aggregating cases alike in character, and therefore fitted 
to produce the special experience so useful in their treat- 
ment, this opportunity of study entailed upon us certain 
obligations to the profession. The responsibility which 
was involved in the possession of such rare experience 
we endeavored conscientiously to meet. Careful notes 
were taken by the surgeon or the resident of every case, 
and were methodically continued until the time at which 
the patient left us; while in many instances the utmost 
care has been taken to collect, in the interval which has 
elapsed since the war, such details of later history as were 
needed to clear up or complete the story of symptoms or 
prognosis. 
The experience thus acquired during the war led to the 
publication of a number of communications on various 
subjects. One of these was a small volume on gunshot 
wounds and injuries of nerves,* which has been long out 
of print. I supplemented it, a year ago, by a paper on 
“ The Diseases of Nerves resulting from Injury,” which 
was published in the medical volume of the Reports of the 
U. S. Sanitary Commission; but as this volume is bulky 
and costly, and as neither it nor the monograph before 
mentioned at all cover the ground which I propose to oc- 
cupy in the following pages, I still feel that there is room 
for my present work. 
The study of the natural history of any class of diseases 
so constantly relates itself to the healthy workings of the 
* Gunshot Wounds and other Injuries of Nerves, by S. Weir Mitchell, 
M.D., Geo. E. Morehouse, M.D., and Wm. W. Keen,M.D. J.B Lip- 
pincott, & Co., Philadelphia, 1864, pp. 164. 12 
INJURIES OF NERVES. 
organs involved, that I need scarcely apologize for follow- 
ing many good examples in the introduction of prelimi- 
nary chapters upon the anatomy and physiology of nerve 
trunks. Since, however, these are subjects more or less 
familiar to all physicians, I have omitted much that is to 
be found in the physiology of nerves which has no near 
relation to the practical wants of my subject. CHAPTER II. 
ANATOMY OF NERVES. 
Structure of nerves.—The nervous system consists essen- 
tially of receptive or controlling ganglionic centres, and 
of the nerves which connect these with one another and 
with the skin, muscles, and viscera. Nerves are usually 
divided into those known as cerebro-spinal and those be- 
longing to the great sympathetic system. The former 
chiefly concern us at present, since, indeed, the latter are 
rarely injured, and since their diseases have only of late 
begun to claim attention. The former, often known as 
nerves of animal life, are such as emerge from the en- 
cephalon or from the spinal axis, and carry to every part of 
the body excitations originating in the great centres, or 
in turn bring to these the numberless impressions arising 
from without, or having birth within the tissues them- 
selves. Yet, varied as seems to be the character of the 
messages with which they are charged, an astonishing 
sameness of structure marks the organization of all these 
fibres. 
The encephalic nerves have certain peculiarities of 
origin and of exit which we may have further occasion to 
mention in connection with the forms of injury to which 
these trunks are liable. 
The spinal nerves arise from either side of the medulla 
by two roots, distinguished as anterior and posterior, each 
having a number of rootlets. Those which form the pos- 
terior root pass through a small ganglionic enlargement; 
those of the anterior stem unite without passing into a 
(13) 14 
INJURIES OF NERVES. 
ganglion; and both sets of fibres on coming together con- 
stitute one spinal nerve. The anterior root is motor in 
function; the posterior, sensory: the former carries mes- 
sages from, and the latter to, the nerve centres. Thus 
constituted, the compound nerve passes outward until 
its fibres, separating anew into their physiological con- 
stituents, enter the muscles on the one part, or are 
distributed to the surfaces upon the other. 
The nerve so made up has, at an early part of its course, 
certain relations to the chain of sympathetic ganglia, with 
which there is probably a mutual interchange of filaments. 
Besides the various fibres devoted to forms of sensation 
and to motion, whether vasal or muscular, each nerve 
is by some authors supposed to possess nutritive or trophic 
filaments, which may be derived either from the spinal 
centres or from the sympathetic system,—a point as yet 
undetermined. 
The trunk of each of the spinal nerves is surrounded 
by a neurilemma, or general sheath, which has the same 
relation to the nerves as the myolemma has to the mus- 
cles. It has been best described by Iiobin, in 1854, and 
still further by Sappey,* in 1868. This sheath surrounds 
the nerve at its escape from the cord, sends out prolonga- 
tions which pass in between the separate bundles and 
fibres, and dividing and subdividing, as the branches be- 
come smaller, follows them through their multiplied 
divisions until it envelops with a delicate membrane the 
primitive fibres themselves, and is lost to view just before 
these end in the muscles or the sensitive surfaces. The 
portion which covers the ultimate tubules has certain 
peculiarities of structure to which I shall presently refer. 
The sheath of the main nerve trunk, and of its lesser 
divisions, is composed of fibrous tissue, the strands of 
* Journ. de l’Anat. et de Phys., 1868, t. v. p. 48. ANATOMY OF NERVES. 
15 
which, running in every direction, and crossing each other 
at all imaginable angles, leave between them minute 
areolae of irregular form. Within, upon, and about the 
fibrous sheath, a considerable amount of fine adipose tis- 
sue exists in the primary, and even in the secondary, di- 
visions of the nerve. It is met with in the most emaciated, 
and follows chiefly the track of the neural blood-vessels, 
or is found collected here and there in small masses. 
Contrary to the common opinion, Sappeyhas found that 
the vascularity of the nerve sheaths is greater than that of 
ligaments, tendons, or aponeuroses, and approaches in this 
respect the spinal or cerebral pia mater. 
The arteries are exceedingly numerous, and lie chiefly 
between the walls of the fibrous partitions in the spaces 
formed by their juxtaposition. The veins, sometimes 
single, at others double, form, like the arteries, an intri- 
cate plexus, but neither are met with in the sheath of the 
ultimate nerve fibre. 
The nerve sheaths also possess nerves which follow the 
path of the vessels, and are less and less numerous as the 
nerve branches, until, on the smaller divisions, they are 
said to be absent. Sappey has described them as nervi 
nervorum, a phrase to which there is no objection, unless 
we attribute to the words too large a physiological signif- 
icance, since, in reality, these fibres are rather nerves of 
the sheath than of the nerves themselves. They in all 
respects resemble other neural fibres, except that they are 
unusually minute. Each nerve, as we follow it with the 
naked eye, surrounded and protected by its neurilemma 
of connective tissue, is capable of being further resolved 
by the microscope into rodlets or fasciculi, known as the 
primitive fibres or tubules. Around each collection of 
these is the delicate sheath which Robin has admirably 
described as the perineurium. The structure of this cov- 
ering is very simple. It is composed of an almost homo- 16 
INJURIES OF NERVES. 
geneous, yet at places longitudinally striated, substance, 
dotted more or less with nuclei and with minute gray 
molecular granules. 
When the primitive bundles of nerve fibres exchange 
filaments with others, as in a plexus, their peculiar sheaths 
accompany them until the single nerve tubules approach 
a free termination, when the sheath ceases to be visible. 
Should the tube end, however, in a corpuscle of Pacini, 
the sheath is continuous with that which covers these 
bodies. Neither nerves nor vessels have, in man at least, 
been traced into these ultimate sheaths. 
Within this covering pass the ultimate nerve tubules, 
the structure of which has been the subject of numerous 
investigations. According to the latest authoritative ob- 
servers, the nerve tubule consists of four distinct parts: 
1st. The sheath of Schwann, or tubular membrane. 
2d. The medullary matter, or white substance of 
Schwann. 
3d. The axis cylinder. 
4th. The elements of the axis cylinder, which may be 
one or many fibrils. 
This complex structure only becomes visible in conse- 
quence of post-mortem changes or the action of reagents, 
so that the fresh nerve fibre looks like a pellucid, rod. 
The sheath of Schwann is described as a thin, delicate 
membrane, only perceptible when torn or treated by 
reagents, or when excessive atrophy has removed its con- 
tents. Within this envelope is found the medullary matter, 
which is transparent, semi-fluid, and of a high refracting 
power, which gives to it the appearance of possessing a 
double contour or outline. In chemical composition it is 
undoubtedly fatty. It is this substance which gives to the 
nerves a white hue, and the absence of which causes them 
to look translucent or gray. It is wanting in certain 
nerves. ANATOMY OF NERVES. 
17 
The cylinder axis is a flexible rod of azotized matter 
which fills the tube formed by the white medullary tissue 
around it. When the nerve is torn, the axis cylinder can 
sometimes be seen projecting, button-like, from the torn 
end of the tubular membrane and medullary substance. 
Numerous conjectures have been formed as to the ulti- 
mate structure of this portion of the nerve tubule; some 
having described it as composed of minute longitudinal 
fibres, while others regard it as made up of laminae placed 
one upon another. Every physiological reason would teach 
us, however, to accept with Schultze, in Strieker’s “ITand- 
buch,” the belief that the ultimate anatomical neural 
element is what he terms the primitive fibril,—of which a 
number, great or small, is needed to make an axis cylin- 
der,—so that the primitive fibril is the essential nerve 
element around which, or around groups of which, may 
be the medullary sheath and the sheath of Schwann,— 
although of the modifications in physiological function 
which these impress upon it we know absol utely nothing. 
Fromman, and more recently Grandry,* by exposing 
the nerves to a peculiar treatment with nitrate of silver, 
reached the conclusion that the cylinder axis is composed 
of disks superimposed and isolated by a substance differ- 
ing from them in composition. I have verified these 
observations on the sciatic nerve of the rabbit with prep- 
arations made by Dr. Keen, and obtained the same result, 
so that it seems difficult, considering the regularity of the 
structure thus brought out, to reach any other conclusion 
than that the axis is probably less simple in construction 
than has been believed. If we admit with Schultzef and 
Strieker that this substance also possesses longitudinal 
striae, the likeness to the anatomical disposition of the 
* Journ. de l’Anat. et Phys., 1869, p. 289. 
f Disc. Acad. Bonn, Aug. 1868. 18 
INJURIES OF NERVES. 
muscle would be remarkable,—a likeness, I may add, for 
which there may also be some physiological foundation. 
The mode in which the nerve tubule relates itself to 
the centres and to the exterior organs is full of interest. 
It appears now to be pretty generally admitted that the 
tubule ma}’ finally be traced into the cells of the ganglia 
composing the spinal medulla and the brain, and that 
before joining these cells it loses its sheath and white 
covering, becoming thus reduced to the single element of 
the axis cylinder. It has been inferred from this that the 
latter part is the essential portion of the ultimate tubule, 
and that the exterior portions are merely meant to serve 
for protection or for insulation. 
Observers are also well agreed that a similar loss of the 
external medulla and sheath, and a like thinning of the 
axis cylinder, is usually observable in the peripheral 
extremities of nerve tubules; but the most extreme di- 
versity of opinion is held as regards the manner in which 
they terminate and as to the relation they bear to muscle, 
on the one hand, and to the sensitive surfaces on the 
other. 
Perhaps no questions in micrology have been less dis- 
tinctly answered than these. The mass of observers agree 
that the sensitive nerves may be traced for the most part to 
a plexiform series of loops which underlie the skin and 
other sentient surfaces. According to Beale and some 
others, these plexiform series constitute the true peripheral 
termination of many sensitive nerves, which, returning 
again to their central cell connections, form, as it were, a 
neural circuit. On the extreme outer loops, Dr. Beale 
located little masses of germinal matter, which he pre- 
sumes to have an office connected with the incessant 
maintenance and increase of these ultimate loops,—a view 
which has been much controverted. 
The appearances so described have of late been other- ANATOMY OF NERVES. 
19 
wise interpreted by Langerhaus.* He considers “that 
processes of non-mednllated nerve fibres from the cutis 
penetrate between the cells of the rete Malpighii, exactly 
in the way described by Hager and Cohnheim as the 
mode of termination of nerves in the cornea. These nerve 
fibrils pass again into small cells lying between the deeper 
cells of the rete mucosum, whence fine fibrous outrunners 
enter the upper layers, to terminate finally in slightly 
clubbed extremities just beneath the horny layer.” These 
have no relation to tact corpuscles, and the research of 
Langerhaus, in which Strieker seems to have faith, tends 
to weaken the belief in terminal peripheral nerve loops 
for which also physiological ground is wanting. 
On the other hand, while it is as yet uncertain whether 
the sensitive fibres end externally in loops or in absolutely 
free ends, it is generally held that a vast number are ex- 
ternally related in some way to the little bodies known as 
the corpuscles of Meissner, of Vater, or Pacini (Yater, 
Pacinische Korperehen), and of Krause. The latter are 
found chiefly on mucous surfaces, those of Pacini in the 
submucous cellular tissue, the mesentery, the muscles, and 
the papillae of the derm. These bodies are most numerous 
in the regions possessed of great tactile sensibility, such as 
the cushions of the fingers,—M. Meissner having counted 
eight hundred in a square line of the palmar face of the 
last phalanx of the index finger. 
The structure of these corpuscles does not differ so 
essentially as to induce the belief that they must have 
different physiological functions, were it not for their 
varying anatomical relations to tissues. 
The tactile corpuscles of Meissner, for instance, consist 
of “oblong oval bodies tolerably distinct from the re- 
mainder of the digital papillae in which they lie. They 
* Strieker’s Comp. Histol., p. 187 ; New Sydenham Soc. edition. 20 
INJURIES OF NERVES. 
are generally rounded off at the upper and lower ends, 
and do not exhibit the longitudinal striation as do the 
Pacinian bodies, but, on the contrary, transverse nuclei.”* 
Two nerves can be usually traced to these bodies, but their 
after-relation to them is less clear. In some cases the 
nerve seems to envelop the corpuscle spirally, in others, 
to he lost in the centre of the mass. I have very little 
doubt that in some instances of local nervous disease the 
starting-point lies in the dermal nerve papillae. In a case 
to which I shall have to refer, the corpuscles of Pacini 
were certainly both too large and too numerous, and in 
one which I myself have seen, there was some probability 
that a neuroma of the thumb was merely an overgrown 
tact corpuscle. 
The corpuscles of Pacini consist of many concentrically 
arranged layers of connective tissue, always becoming 
more closely packed towards the centre, and surrounding 
a cavity filled with soft, abundantly nucleated and easily 
alterable material, which coagulates after death, and into 
the interior of which the nerve fibres penetrate. These, 
after they have lost the medullary sheath and the sheath 
of Schwann,—which latter becomes continuous with the 
laminated sheath of connective tissue investing the cor- 
puscle,—consist only of the axis cylinder, which terminates 
in a little bulb. 
The nerve corpuscles of Krause, described and depicted 
by him as existing in the conjunctiva, genitals, and other 
mucous surfaces, differ from the Pacinian corpuscles only 
by the absence of a thick, laminated investment, f 
Most authors have held that these little bodies are ap- 
paratuses of reinforcement (Vulpian) for the impressions 
* Virchow, Cellular Pathology, translated by Dr. Chance, p. 277. 
New York, 1861. 
f Scliultze, in Strieker’s Histology, New Syd. Soc. Transactions, p. 168. ANATOMY OF NERVES. 
21 
to which the sensitive nerves are submitted, or that each 
corpuscle is a centre of ganglionic matter, without which 
certain impressions cannot originate,—a view sustained, to 
some extent, by the analogy of some of the special senses, 
but contradicted by a host of pathological phenomena. 
Their function may possibly be protective, as regards the 
nerve ends, but that they have some relation to general 
sensibility, or to touch, seems alone clear. Rauber—who 
has stated the number of the deep-seated corpuscles of 
Pacini at 2142, too small a number for large relations 
to sensation—believes them to be the sensory organs as to 
the muscles. Yulpian states very justly that except as to 
the well-known mesenteric connection between certain 
Pacinian bodies and the sympathetic nerve, we have no 
clear information as to the peripheral distribution of this 
nerve system, nor are we much better instructed in the 
mode in which nerves terminate on vessel walls, a subject 
of daily increasing interest.* 
Since the researches of M. Rouget and their general 
confirmation by Krause and Kuhne, there is less difference 
of sentiment as to the motor termination of nerves. The 
nerve fibre undergoes division, and each branch on enter- 
ing the sarcolemma loses its sheath of Schwann, which 
becomes continuous with the sarcolemma. The axis cyl- 
inder alone enters, the medullary matter as in other cases 
having previously disappeared. The cylinder axis of the 
nerve spreads out over the muscle substance in a granular 
mass, which is slightly prominent, and as to the true 
nature of which observers have disagreed. According to 
Trinchese, and to Rouget’s latest researches, the granular 
cone, now known as the motor plate, conceals a delicate set 
of fine loops or plexuses, which are the true terminations 
of the motor nerve. Dr. Beale, however, believes that 
* See Duchenne, translated by H. Tibbits, M.D. London, 1871, p. 153. 22 
INJURIES OF NERVES. 
the terminal nerve fibre of motor nerves does not perfo- 
rate this sarcolemma, but forms a network on its surface. 
This view, Kiihne contends, is due to imperfect observa- 
tion, though we confess that Dr. Beale’s drawings, if cor- 
rect, scarcely admit any other interpretation than that 
which he places on them. 
Before passing to the consideration of the laws which 
control the passage of impressions over nerve fibres, there 
are a few points to be considered which concern the gen- 
eral or rational anatomy of nerves, and derive importance 
from their connection with disease or wounds of these 
parts. 
Protection of nerves, owing to tlieir physical peculiarities.— 
The fibrous character of the grosser nerve sheath, and 
the fact of each nerve being composed of a multitude 
of fibres, give to the nerves far more strength or power 
of resistance than might be supposed to belong to it, 
if we considered only the delicate structure of the 
neural substance itself. Dr. P. Tillaux* has examined this 
subject with the following results: The sciatic nerves of 
two fresh bodies were laid bare at the level of the pop- 
liteal space, then all the other parts of the member having 
been cut across so that the limb remained attached to the 
body by the nerve trunk alone, traction was made upon 
the limb in the direction of the nerve. A power equal to 
54 to 58 kilogrammes—108 to 116 lbs.—was found to be 
necessary in order to rupture the nerve. To break the 
median or ulnar, under similar circumstances, a force of 
40 to 50 lbs. was requisite. In practice it has been observed 
that when a limb is torn oft’, the nerve frequently gives 
way at a point above that at which the other parts are 
torn. Thus the sciatic may be broken oft’ at the level of the 
buttocks, owing to the external and posterior portions of 
* Tillaux, Aff. chir. des Nerfs, p. 11. ANATOMY OP NERVES. 
the leg having been dragged off, while the tissue of the 
thigh, save for the nerve rupture, remained intact. Actual 
experiment on the dead body showed, according to Til- 
laux, a like tendency on the part of the greater nerves to 
tear apart at some point usually near or at a joint. Thus 
the sciatic gives way where it runs under the pyramidal 
muscle, at the line of the sciatic notch, and the median 
and ulnar part at the bend of the elbow, when traction 
has been made on a lower portion of their trunks. These 
facts may, in rare instances, be of value to the surgeon, 
and might possibly determine, in certain cases of torn 
limbs, the point for amputation. 
The toughness and elasticity of nerves are also shown 
in some cases of disease and injury. Romberg and the 
author just quoted remark upon the extent to which they 
will stretch without breaking. Thus the median or ulnar 
will gain 15 to 20 centimetres in length before parting. 
I have also noticed many times, as other observers must 
have done, the same physical quality in nerves; but it has 
seemed to me far more important to know how far this 
extension may go without loss of physiological properties 
in the portion stretched. We have all had occasion to 
watch the slow lengthening of nerves pushed aside by 
morbid growths, but in these cases it is probable that a 
constant process of repair in the interstices of. the nerve 
accompanies the extension and limits the mischief. A 
healthy nerve will bear an amount of pressure and han- 
dling, which both in surgical and physiological operations 
has occasioned me much surprise. Several years ago I 
endeavored to estimate the limits of this capacity to en- 
dure extension by a series of experiments on the sciatic 
nerve of the rabbit. 
I give a single experiment to illustrate these remarks. 
The sciatic nerve of a rabbit was separated from the point 
of exit down to the knee; it was then cut across at the 24 
INJURIES OF NERVES. 
highest level and attached to a string, which passed over 
a little roller and carried a pan on which weights were 
placed. The nerve was then tested by mechanical and 
electrical irritation, and having been found to respond, 
weights were placed on the scale-pan, and these, with the 
amount of stretching of the nerve, were noted. In this, 
and in other experiments on frogs, it seemed to me that 
the nerve bore best a slow addition of a weight, which, 
suddenly added, caused abrupt loss of physiological prop- 
erties. As the extension was increased, the muscles were 
thrown into a state of irregular convulsive activity, which 
did not cease altogether when the nerve was for a time 
allowed to relax. Slight mechanical injuries ceased to 
cause reaction when the nerve had elongated to the extent 
of one-fifth, but electricity still produced muscular con- 
traction until the lengthening was equal to f of an inch in 
three inches. It is very probable that much less stretch- 
ing will be found competent to destroy the perfect control 
of the will over the muscles, or to interfere with the con- 
veyance of delicate sensory impressions to the centres. 
I have seen a curious illustration of the degree to which 
a nerve may be meddled with before losing its power to 
carry impressions. In a case of hospital gangrene of 
the thigh, resulting in an enormous cavity, the sciatic 
nerve was left intact. During one of the dressings, this 
large trunk was at first quite roughly drawn out of the 
wound, and afterwards pushed down to the bottom or 
side of the cavity by the dressing employed. Some pain 
resulted, as may be supposed, but the sense of touch 
was scarcely disturbed. I witnessed the removal of 
the dressings. The nerve must have been pushed fully 
four or* five inches out of its path, and very much 
elongated. 
The fibrous nature of the coarser nerve sheaths serves to 
protect the fibres from the ravages of disease, of which fact ANATOMY OF NERVES. 
25 
the case I have just mentioned is a fair illustration, al- 
though few surgeons are without similar experiences. 
Besides this insurance against certain forms of disease, 
the structure of the nerve tibre, and its vascular relation- 
ships, also contribute to its safety, for as each nerve fibre 
has its sheath, the essential axis cylinder is well protected; 
while also the absence, in man at least, of blood-vessels 
within the delicate covering described by Robin, serves 
to prevent, to some extent, the access of inflammation. 
Thus it is that the nerves are able to traverse, uninjured, 
parts in divers states of degeneration or inflammation. 
It is also this sheathing by a non-vascular envelope that 
limits to a degree the changes caused by neuritis, and 
enables the non-vascular fibres to recover rapidly and thor- 
oughly from such disease, because during inflammation 
the nerve fibres suffer principally from pressure, owing to 
effusion in and about the vascular portions of the nerve. 
The toughness and general elasticity of nerve trunks 
sometimes serve a useful purpose in cases of ball wound, 
and I have repeatedly seen nerves escape total destruction 
from missiles simply because they were thrust aside, in- 
stead of being divided. Some of these escapes, which can 
be explained in no other way, are very interesting. They 
are most apt to occur where a missile has passed through 
a limb midway between two joints. On the other hand, 
injuries of nerves in connection with bone or near to 
joints are likely to be severe and lasting, because at these 
points and in these positions the nerve trunk is more 
firmly anchored than elsewhere, and shares in every in- 
jury which directly affects parts in its near neighborhood. 
When a spinal nerve emerges from the intervertebral 
canal it is motor and sensory, by the union of the anterior 
and posterior roots, which represent motion and sensa- 
tion respectively. Whether or not these fibres become 
at once scattered so that every part of the area of the 26 
INJURIES OP NERVES. 
nerve contains an equal share of the nerve tubes, both 
of sense and motion, is not at present very clear. Such, 
however, is the popular medical belief, though there is 
a good deal of reason to think that the nerve filaments 
of either function remain in bundles; because, as we 
shall see later, it is very common to find that a nerve 
trunk, injured by a missile, has suffered in its sensory 
or motor functions alone, which could scarcely be ac- 
counted for upon any other supposition than that last 
mentioned. Any other explanation must presuppose some 
greater susceptibility to injury in one set of fibres than in 
another. 
In passing from the centre to the periphery, the nerves 
give off branches which, as a rule, leave the main stem at 
an acute angle, and more rarely at a right angle. Herves 
in certain positions are liable during movement of limbs 
to be acutely bent, as happens at the elbow; and although 
such flexion is harmless when not prolonged, it is liable 
to cause loss of function when continued for some time, 
as may be felt by retaining the arm in a position of ex- 
treme flexion for ten or fifteen minutes.* 
In their branchings nerves come into relation with 
other nerves, and give or get fibres; but the function of 
these is not altered thereby, nor do the nerve tubes in 
man anastomose in the sense in which vessels do. 
A considerable number of nerve fibres appear to form 
loops, for the most part having their convexity towards 
* It would appear, however, from the following instance, that recovery 
from this may occur when a limb remains bent for long periods. I saw 
lately, at the Hospital for Deformities and Nervous Diseases, a girl whose 
left arm had been bent at a most acute angle for years, owing to the 
cicatricial contraction following a burn. Although at first there was 
some loss of tactile power, at present there is absolutely perfect sensa- 
tion throughout the limb, and the intrinsic finger movements are well 
preserved. ANATOMY OF NERVES. 
27 
the periphery, from which in many cases filaments emerge; 
while in other instances these loops are merely recurrent 
communicating branches. Hyrtl has given numerous 
instances of these. Some of the more familiar are the 
loops of the hypoglossal, the return upwards of the re- 
current laryngeal, and the palmar or plantar arcades. The 
chiasm of nerves on opposite sides of the body is more 
rare. That of the optic nerves in man seems to be in 
him the sole instance of a true physiological chiasm, 
since Vulpian* thinks he has proved that in the case of 
the intercommunication of the right and left hypoglossals 
pointed out by Hyrtl, there is no transmission of power 
from side to side; and, indeed, if I correctly understand 
the passage, he would seem to have some doubt as to 
whether there is really an interchange of fibres. 
In man the cerebro-spinal nerves, at least, seem to be 
physiologically limited to their own side of the body, a 
proposition which becomes of some importance in the 
recognition and limitation of paralytic affections. I have 
once or twice felt doubtful as to the strict truth of this 
law as applied to certain traumatic palsies of the face, 
where in rare cases the motor fibres of the upper lip have 
appeared to me to cross over, so that irritation of the 
nerve on the sound side seemed to cause slight muscular 
contractions on’ the diseased side. 
In the lower animals, the existence of any true physio- 
logical chiasm, other than that of the optic nerves, was first 
demonstrated by the author, and his frieud Dr. More- 
house, in the case of the chelonians, all of which have a 
chiasm between the two superior laryngeal nerves, so that 
irritation of the left nerve acts on both the left and right 
lips of the larynx, and vice versa. Guided by this dis- 
covery, my friend Prof. Wyman found similar chiasms in 
* Vulpian, Le9ons sur la Phys. Comp., etc., p. 160. 28 
INJURIES OF NERVES. 
reptiles and birds. lie has also discovered that in frogs 
the nerves of the skin cross the central line of the body. 
I have recently examined frogs to learn whether this 
anatomical crossing involves physiological consequences. 
To test this, the skin of the frog’s back or belly was di- 
vided longitudinally at varying distances from the middle 
line, and then irritants, as biliary and stronger acids, 
were applied to the skin between the central raphe and 
the line of section; no response was obtained to such 
irritations, even in frogs which had been previously ren- 
dered excitable by strychnia. The purpose, therefore, 
of such interchange of nerves must still be considered 
doubtful. 
During their distribution, the nerves from more or less 
remote parts of the nervous system in some localities 
run together, and then separate to reunite and part anew, 
thus forming, by the free communication between neigh- 
boring branches, a plexus or network, from which emerge 
finally the nerve trunks which are to be distributed to a 
particular member. This intricate interlacing seems to 
be merely an arrangement for the interchange of fibres, 
since those which enter the plexus acquire in it no physi- 
ological properties which they did not previously possess. 
A knowledge of these networks is essential to the study 
of nerve wounds, because injuries of the plexuses, espe- 
cially that of the neck, are very common in war, and 
their arrangements enable us to explain in many cases 
the transmission of disease from one nerve to another, 
which is closely related to it in the plexus, or as its 
parent stem. After leaving the plexus, the limb nerves 
are usually distributed with great regularity, anomalies 
being rather uncommon. 
While in most men we may take for granted that nerves 
obey the normal law, it is still important to remember 
that in the arm especially, peculiar and exceptional ar- ANATOMY OF NERVES. 
29 
rangements may occur in the way of unusual interchanges 
of nerve fibres. 
Chassaignac, and, more recently, Mr. Hilton, in his 
thoughtful book on “ Pain and Rest/’ have pointed out, 
as one of the elements of protection to nerves, the fact 
that in most instances the motor nerves enter their 
respective muscles on the under side, so that the whole 
thickness of the muscle is interposed between the nerve 
and the exterior sources of injury. We may add that on 
their first entrance to a limb, the larger nerves lie in the 
leg at the back, or in the arm, upon the inside, where 
they are singularly secure from harm. CHAPTER III. 
NEURO-PHYSIOLOGY. 
Varieties of nerves.—The nerves which connect a limb 
with the centres fulfill the following functions: They 
convey outwardly motor impressions, resulting in volun- 
tary or involuntary motion, as the case may be. They 
carry centripetally the myriads of impressions which con- 
stitute Sensations, or which, unfelt as sensations, are excito- 
motory in purpose. Lastly, a system of nerves, known as 
sympathetic, exercises control over the flow of blood to the 
tissues. Section of these nerves paralytically dilates the 
vessels; galvanization contracts them. This system origi- 
nates in the spinal cord, but there is also evidence that 
certain spinal nerves, unrelated to the sympathetic, possess 
the power to cause directly enlargement of arterioles and 
increase of vasal supply. 
Through this qompound group of nerves occur such 
nutritive changes as depend on increased or lessened flow 
of blood, but these are insufficient to account for all the 
trophic changes which we witness from disease or injury; 
and hence has arisen the belief that there are also trophic 
nerves proper, which, apart from variable blood supplies, 
or in connection with these, bring about in the tissues 
alterations, examples of which I shall have to point out 
from time to time. 
In connection with nerve wounds and their conse- 
quences, we have to deal with alterations due to the 
destruction or irritation of the various fibres of nerves 
(30) NEURO-PHYSIOLOGY. 
31 
which minister to pain, touch, the thermal sense, motion, 
calorification, and nutrition. 
I do not think it desirable to enter as largely into these 
subjects as they would be dealt with in a physiological 
treatise, but I cannot avoid some reference to such por- 
tions of their physiology as either aid us to comprehend 
and relieve nerve wounds, or as are set in new or clearer 
light by the phenomena of these accidents. 
Trophic nerves.—The question which most often pre- 
sents itself for answer to the neuro-patliologist is as to 
the existence or non-existence of nerves directly affecting 
the nutrition of the tissues, apart from the changes in- 
duced in them by the section or irritation of vaso-motor 
nerve fibres. Without attempting to treat fully of this 
matter, for which, indeed, the physiological groundwork 
is still deficient, I shall content myself with stating the 
impressions in this direction which a large experience of 
nerve wounds has left upon my mind. 
When the physiology of the vaso-motor nervous system 
was first elucidated by the labors of Bernard, Brown. 
Sequard, Schiff, and others, it was supposed that it would 
enable us readily to explain the many obscure phenomena 
which arise out of nerve wounds; but despite the able 
arguments of Handheld Jones* and some other observers, 
this hope has gradually faded away, and it is now gen- 
erally admitted that we must seek elsewhere for a 
satisfactory explanation of the facts in question. 
The effects of injuries or sections of these nerves can 
be only to cause either contraction or dilatation of vessels, 
or to put a stop to the pulsatile movements which have 
been seen in minute vessels in many parts of the animal 
economy. These alterations, with the consequent changes 
in blood supply which they bring about, may be direct 
* St. George’s Hospital Eeports, 1868, p. 89 et seq. 32 
INJURIES OF NERVES. 
results of nerve lesions, or may be caused after partial 
nerve lesions b}7 reflex influences originating in the wound. 
Iso matter bow caused, the}7 are limited to too large or 
too small a supply of blood, or to alternations of these 
conditions. 
To test the probability of the competency of vaso-motor 
changes to cause the multiplied lesions which follow wounds 
of the nerves of the limbs, we naturally turn to the sim- 
pler case of injuries of the sympathetic in the neck. 
Section of this nerve merely increases the amount of 
blood which flows in any given time through the tissues 
in which it is distributed, and also causes a rise in their 
temperature. But these changes are not permanent, and 
neither do we find that the face, for example, is then 
subject to spontaneous inflammations or to other trophic 
alterations unless the animal be in bad health. Thus, in 
rabbits long kept confined, I have frequently seen inflam- 
mation of the conjunctiva and cornea follow such sections, 
but not in their more vigorous companions, and such was 
also Bernard’s experience. Moreover, artificial lesions in 
the latter class appear to heal with unusual celerity. 
Like Weber, I have made many attempts to bring about 
trophic changes in the face by irritating and partially 
wounding the sympathetic, but my efforts have uniformly 
failed; nor have like experiments, such as Lister’s, upon 
the sympathetic nerves in the limbs of the frog, been any 
more fortunate. 
Of course, section of these nerves in their course through 
the compound nerves of the limbs of man is not without 
indirect influences on the life of the tissues, but unhappily 
we need as yet early thermometric observations after 
nerve wounds of the extremities to complete their history. 
In speaking of the effect of nerve wounds on tempera- 
ture, I shall again approach this subject. At present it is 
only necessary to say that at remote periods after total NEURO-PHYSIOLOGY. 
33 
sections of nerves in a limb, there are usually lowered 
temperature and a condition of passive congestion, while 
the still more remote future affords some evidence of 
greatly lessened blood supply; the reasons for which 
changes are not very difficult to trace. Under these cir- 
cumstances the life of the limb is lowered and exposed 
parts are easily injured; but repair, though sometimes 
slow, still occurs, and may even be unusually rapid. 
I have watched many such cases of complete separa- 
tion of a limb, or parts of a limb, from all neural influence, 
and have failed to see any inevitable consequence except 
general atrophy, with usually muscular contractions, and 
a sallow, unhealthy look of the skin, which is apt to be- 
come scaly and rough. The nails grow as usual, perhaps 
a little more slowly, and the hair is commonly unchanged. 
How and then I met with one of these cases in which 
whitlows occurred, or ulcers formed on parts which either 
were or were not exposed to mechanical injury. In most 
instances these ulcers healed easily, in some cases with 
unusual facility. We can only conclude from these facts 
that a certain individuality of cell-life controls the results, 
and that the cell-life of one man so differs from that of 
another as thus to present us with varied phenomena 
under what seems to be equality of conditions. At all 
events, here, if in any case, we have total vaso-motor palsy, 
and for a long while, at least, probably an excessive blood 
supply, but no constant symptom save atrophy, and in no 
case hypertrophy. But atrophy may, and does, take place 
from nerve injury without notable changes of temperature, 
so that we are by no means justified in considering this 
the only constant result of total nerve section, as due to 
vaso-motor palsy; 
After partial nerve wounds there may be contraction of 
vessels from direct irritation, or reflectively produced 
dilatations or contractions. I believe that I have seen 34 
INJURIES OF NERVES. 
each of these conditions in limbs, or portions of limbs, and 
have watched in vain for their results in the way of nutri- 
tive mischief. 
The best cases are those in which prolonged spasm of 
the vasal muscles of one limb has been caused by wound 
of another. In such rare cases the temperature may be 
remarkably lowered for weeks, thus showing lessened 
blood supply without the appearance of any remarkable 
nutritive changes. 
If the vaso-motor nerves were alone responsible for the 
existence of all the lesions which follow nerve wounds, it 
would be reasonable to expect always to meet with some 
rise or fall in temperature. Such, however, is not the case, 
and I have frequently met with profound trophic changes 
unattended by thermal perturbations; and the same re- 
mark has been made by other neuro-pathologists. 
It is also difficult to explain, on the theory of changes 
in vasal supply, the completeness of some of the trophic 
conditions attendant upon nerve wounds, or central dis- 
ease, for it seems scarcely possible to conceive that with- 
out the least apparent change in the appearance or color 
of the related part there could be, from lack of blood, or 
its excess, that absolute arrest of growth which I have 
shown to occur for a time in the nails after certain cerebral 
palsies. 
For such reasons, then, I am unwilling to admit that 
vaso-motor nerve lesions have any other share in the pro- 
duction of the tissue changes which may follow nerve 
wounds than merely to prepare the ground for their pro- 
duction by other more direct agencies. 
In 1858, Brown-Sequard first distinctly expressed the 
opinion that “the nervous system determines an increase 
of the attraction exerted upon the blood by the living 
tissues, and, in this case, the phenomenon is attended 
by dilatation of blood-vessels. The nervous system acts NEURO-PHYSIOLOGY. 
35 
directly and originally upon the parenchyma of the tis- 
sues.” In 1860, Samuel,* resting upon facts such as I 
have urged in regard to the vaso-motor nerves, rejected 
them as the sole causes of nutritive changes, and declared 
his theory of trophic nerves as distinct fibres concerned in 
governing the nutritive conditions of the tissues. 
This observer conceived that the trophic nerves have 
their centres in the intervertebral spinal ganglia, or in 
cerebral ganglia having like physiological powers. He 
distinguished them as centripetal nerves, receiving and 
conveying inward impressions connected with trophic 
changes; and centrifugal nerves which, when palsied, give 
rise to atrophies, and, when irritated, to inflammations. 
Thus, while he regards nutritive activity as the result 
of a force inherent in the molecules or cells of the tissues, 
he looks upon the trophic nerves as the means of regulat- 
ing their changes, increasing, retarding, or enfeebling 
them, as the case may be. 
The experiments on which he chiefly bases this hypoth- 
esis have failed in the hands of other observers, and as yet 
there is no absolute physiological proof of the existence 
of such nerves. The anatomical demonstration of these 
fibres is equally wanting, so that at present the justifica- 
tion for their existence lies in an apparent necessity for 
their presence which so impressed Duchenne as to cause 
him to remark that “ if we had no knowledge of such 
nerves, we should be forced to invent them.” 
If, in fact, we exclude vaso-motor influence as capable 
alone of explaining the pathological changes which follow 
nerve wounds, we are forced to fall back upon the nerves 
of motion and sensation, or to believe in a system of 
independent trophic nerves. The discovery by Baren- 
sprung of inflammation of the intervertebral ganglia of 
* Trophischen Nerven. Leipzig, 1860. 36 
INJURIES OF NERVES. 
nerves, in the track of which in the skin were developed 
herpetic eruptions with neuralgia, appeared to be a valu- 
able confirmation of Samuel’s views; but the attendant 
neuralgia, showing an affection of sensory fibres, weakens 
the evidence which would have been perfect if there 
had been a painless herpes with some disease of the 
ganglia. 
The phenomena of nerve wounds, as I have seen them, 
lend no conclusive support to the theory, and there are in 
them, as in many other pathological facts, certain argu- 
ments in favor of the possibility of disorders of nutrition 
being capable of production by the irritation of ordinary 
nerves of sensation, and, indeed, of motion. 
Among these are the grave changes which sometimes 
occur in tissues affected with neuralgias, and also the phe- 
nomena of muscular atrophies. It is, moreover, to be 
remembered that the functional activities of skin and 
muscle have some distinct and close relations to the pres- 
ervation of their nutritive life, and that pathological irri- 
tations do not traverse nerves of motion or sensation in 
one direction only, but disturb them really from end to 
end, and may thus, in any case, come to influence abnor- 
mally the tissues in which lie their ultimate filaments. At 
present it seems alone clear that while neural and central 
irritations alike are competent to pathologically disturb 
the status of nutritive health, we are without absolute 
proof of the existence of true trophic nerves, devoted 
solely to regulating nutrition, and are equally without just 
reasons for asserting that the nerves of sense and motion 
may not be largely concerned in propagating to the tissues 
irritative and other influences quite competent to occasion 
disease. 
There exist, in fact, certain observations of Vulpian 
and Phillipeaux which make it probable that the nutritive 
integrity of tissues depends chiefly upon that of the nerves NEURO-PHYSIOLOGY. 
37 
concerned in their several functions, and that to destroy 
a sensitive nerve is to affect injuriously the skin and its 
appendages, while section of a motor nerve is equally cer- 
tain to bring about atrophy in the muscle. • 
Thus, when the lingual sensory nerve was cut, the 
mucous surface of the tongue and the papillae became 
wasted, without muscular changes, while these alone fol- 
lowed division of the hypoglossal nerve. Since, say these 
observers, the hypoglossal possesses also a few sympathetic 
and sensory filaments, it is still possible that some of these 
may he concerned in the result, so that direct experiments 
on this nerve do not decisively settle the question. It has 
been found possible, however, by lesions of the floor of 
the fourth ventricle, to paralyze the hypoglossal at its 
origin without involving any other nerves. Yet, under 
these circumstances, the atrophy follows as is usual after 
peripheral sections, and leaves us with the fair presumption 
that the nutritive life of the muscles depends chiefly upon 
their motor nerves. 
There is at present in the Pennsylvania Hospital a rare 
case which corroborates these views. A small pistol-ball 
traversed the neck, and, without causing any graver lesion, 
cut the left hypoglossal nerve. This accident resulted in 
motor palsy of one-half of the organ, with atrophy of the 
muscles, but left undisturbed the senses of touch and 
taste, as well as the nutrition of the mucous surface. 
The mechanism by which neural irritations or palsies 
give rise to inflammations, eruptions, and the like, is 
made more clear by the attendant facts in regard to the 
secretions of the skin. These, as I shall show, are some- 
times lessened or annihilated, sometimes increased, and 
more often altered so as to become excessively acid and 
offensive. It is quite conceivable that the products of 
disintegration in the deeper tissues are similarly affected, 
so as to be sometimes either excessive or deficient, and 38 
INJURIES OF NERVES. 
sometimes abnormal in character; meanwhile the irregu- 
lar and retarded circulation fails to remove these products 
with even the normal rapidity, and their accumulation 
may come to act as local poisons to limited regions of 
tissue, and so he efficient in bringing about the diseased 
conditions of which I have spoken. 
The most interesting generalizations as to trophic 
changes consequent upon lesions of nerve trunks are 
these : 
Total section of the main nerves of a limb results 
invariably in atrophy, but not necessarily in any inflam- 
matory conditions. It does not, however, forbid these, 
nor is repair always interfered with to any great extent. 
Partial wounds of nerves, and especially gunshot le- 
sions, are apt to give rise to a large number of trophic 
changes in the skin, hair, nails, areolar tissue, and muscles. 
Except the entire arrest, for a time, of nail growth, every 
trophic alteration capable of arising from injuries or dis- 
eases of the centres is also to be met with as a conse- 
quence of wounds of the nerves. 
Section of muscle nerves causes atrophy and contrac- 
tion of the related muscles. Partial wounds occasion 
various degrees of wasting, with more or less loss of mus- 
cular sensation, and impairment or loss of power to re- 
spond to electric, galvanic, or mechanical irritation. 
Exceptional cases exist of atrophy without defect of ex- 
citability under stimulation. 
Trophic changes in the skin, hair, and nails are never 
present after nerve wounds without some affection of sen- 
sation, such as dyssesthesia, anaesthesia, or hyperesthesia; 
but any of these latter states may exist without the nutri- 
tive alterations in question. 
Trophic changes are most prone to follow wounds of 
nerves which are distributed to the hands and feet, and 
more rarely occur when the injury has involved only the NEURO-PHYSIOLOGY. 
39 
nerve branches which supply the upper portions of a 
limb. 
Nerves of pain.—There is a good deal of doubt as to 
whether or not the various forms of sensory impressions, 
such as heat, cold, tickling, etc., affect the sensorium 
through distinct sets of fibres, or whether they travel on a 
common track with impressions of touch and pain. These 
latter are, certainly, in a manner distinct; but, although 
it has been made clear that one or more of the varied 
forms of sensory expressions may disappear without any 
other being lost, this is no absolute proof that separate 
fibres are needed for their conveyance to the centres. 
Brown-Sequard is disposed to admit the existence of a 
number of such sets of nerve tubes; but while there is 
a good deal in general nervous pathology to make it 
probable that the distinction of sensations depends upon 
their central discrimination alone, the phenomena of 
nerve injuries tend to discredit by negative proof the 
theory of the existence of numerous sets of sensory nerve 
fibres, as I shall have future occasion to point out. 
Of the exact nature of the affection of nerve matter 
which produces pain we know but little. In general, for 
the causing of pain we must have mechanical impressions 
far more severe than those which excite the nerves of tact 
and temperature; while it would also seem that neural 
excitation attaining the grade of pain is possible, as in 
many neuralgias, without the least evidence of visible 
organic alteration of tissue. 
In the normal condition, the sense of pain is very un- 
equally distributed as regards the skin surfaces, and bears 
no definite proportion to the acuteness of the tact sense. 
Indeed, there are certain portions of the tissues in which it 
is extremely deficient, as the back and a limited space 
over the tibia. As a rule, the thigh is less sensitive than 
the arm, the leg than the forearm; but as no complete 40 
INJURIES OF NERVES. 
study of this sense has been made, it is impossible to carry 
such comparisons further. In the lower animals the dor- 
sal skin seems, in some cases, to possess little or no feeling, 
so that I have actually made incisions through this part 
in dogs and rabbits without seeming to produce any pain 
whatsoever. The interior organs are variably provided, 
as to the pain sense, some of them appearing to have little 
or none of this form of sensibility; yet in all, even in the 
bones and intestines, lie remote capacities for torture 
which seem capable of development in the presence of 
diseased states. 
Are we to suppose that there exist always in these 
organs pain nerves, and that only once, perhaps, in a life- 
time these filaments are to he aroused into activity? Or, 
as regards the skin, how shall we deal with the like diffi- 
culty if we choose to believe that everywhere are peculiar 
nerve fibres devoted only to transmitting painful sensa- 
tions? The skin, in this view of the case, must have a 
set of nerves so rarely used that it is difficult to compre- 
hend how they can sustain their organic life uninjured, 
and ready to awaken into functional activity at long and 
irregular intervals. 
I am unwilling, in view of these facts, to look upon pain 
as a distinct sense with afferent tracks peculiar to itself; 
and when we consider also how sensory impressions made 
on nerves purely of special sense may rise to the height 
of being painful, it becomes more and more probable that 
pain is the central expression of a certain grade of irrita- 
tion in any centripetal nerve. 
There is, indeed, every probability that the sensory 
nerves are competent to carry inward a variety of impres- 
sions, which, owing to the peculiar nature of the excita- 
tions they cause in the nerve, are capable of appreciation 
only by the separate centres devoted to their perception, 
so that pain, touch, and thermal excitations may need, in NEURO-PHYSIOLOGY* 
41 
the peripheral nerves, no different channels for their 
passage. 
It is as if through a single tube were spoken various 
languages which could be only understood when, at its 
farther end, they reached the ear of the hearer native to 
each form of speech. There is in physica* science a good 
deal in favor of the view I have so briefly urged, and, 
clinically, something may be said for it. 
We now know that motor-excitations may be made to 
pass over sensory nerves, and vice versa, while in most of 
the instances of loss of pain without loss of tact the lesion 
has been plainly central. In the rare cases of peripheral 
analgesia without anaesthesia, it is quite possible that such 
modifications may have taken place in the nerves as to 
have destroyed the power of the nerve tissues to transmit 
particular forms of excitation. 
Recurrent sensibility.—Although we admit the general 
proposition that the anterier roots of spinal nerves are 
motor, and the posterior are sensory, there is an apparent 
exception to this which has generally been admitted of 
late years. 
When we divide the posterior root of a spinal nerve, all 
sensation is lost to the terminal branches of the mixed 
nerve of which it makes a part. So also is motion utterly 
lost by dividing the anterior root. If, however, the spine 
has been opened with certain precautions, and the nerve 
roots, after exposure, have been left at rest for a certain 
time, it will be found that distinct evidences of sensibility 
may be evoked by irritating the anterior root. Should we 
then divide this trunk, the central end will be found to 
possess no sensibility such as will exist in the peripheral 
extremity, and section of the posterior root will abolish 
altogether these evidences of feeling; so that it becomes 
clear that the fibres communicating sensation to the ante- 
rior root must depend upon the posterior root. 42 
INJURIES OF NERVES. 
The experiments of Bernard, especially upon the recur- 
rent sensibility cf the cranial nerves, seem to prove that 
the sensitive fibres turn backward at different points in 
the nerve route to accompany th6 motor fibres all the way 
to their proper root, and even into the spine itself. The 
author named conceives that the most of these recurrent 
branches are derived from terminal anastomoses of the 
sensitive and motor nerves. Concerning this point, there 
is still some doubt, but the existence of this peculiar sen- 
sibility of the anterior nerve roots is now regarded as an 
accepted fact in science. 
Gubler and Brown-Sequard have both suggested differ- 
ent and ingenious explanations of the so-called recurrent 
sensibility, but neither are satisfactory; so that no one, 
as yet, has offered any competent explanation of the phy- 
siological necessity for the arrangement in question. The 
difficulty of so doing is not lessened by the fact that 
recurrent sensibility does not exist in fishes, and that 
Vulpian failed to detect it in the pigeon. I repeated 
some years ago Bernard’s experiments, and reached the 
same conclusions as he has done. I failed, however, to 
discover recurrent sensibility in the duck and the chicken, 
notwithstanding every precaution to insure success, nor 
was I more fortunate in our large clielonians (Chelonura 
serpentina), which are admirably fitted to be the subjects 
of such experiments. 
Neurility and neural excitants.—Every stimulus capable 
of acting on a nerve causes in it the development of the 
nervous force, the true nature of which is extremely 
problematical. For a long time there has been a decided 
tendency to regard this force as some form or manifesta- 
tion of electricity; but just in proportion as we have come 
to know more of the true relations of the latter force to 
nerve tissue has the probability of the identity of nerve 
force and electric force diminished. NEURO-PHYSIOLOGY. 
43 
Beyond a doubt, certain electrical phenomena exist in 
connection with all nerves and in the presence of all 
nerve action ; but so far from these facts showing that 
nerve force is electricity, their whole bearing is to prove 
quite the contrary. 
There seems, indeed, to be every likelihood that the 
electric states which arise during nerve disturbance are 
merely manifestations related to the states of nervous 
activity, and passively dependent, directly or indirectly, on 
nutritive changes or upon molecular alterations, themselves 
connected with the altered polarity of the nerve during 
its conditions of rest or excitation.* More probably nerve 
force depends, like magnetism, upon peculiar conditions 
of certain matter for its manifestations, so that only where 
these exist can it be studied, while, as regards its kinship 
to electricity, we can only surmise that they are correlated, 
and that the one may give rise, under certain conditions, 
to the production of the other. Besides the common 
arguments against their identity, such as the fact that 
crushing the nerve destroys its power to convey impres- 
sions, while it may still conduct electricity, there are cer- 
tain other objections to the conception of their oneness 
which appear to me to present insurmountable obstacles 
to any such belief. The most formidable of these is the 
difference in the speed with which the galvanic and the 
nerve currents are propagated. Thus, in the frog’s nerves, 
at a temperature of 52° F. up to 70° F., nerve force moves at 
a rate of from 81 to 126 feet per second. In man it is esti- 
mated to travel on motor nerves at a speed of 200 feet a 
second. In sensory nerves the rate at which impressions 
move is about 110 feet per second, with some variation for 
the different nerves. It has also been shown by Munk that 
the speed is not uniform for all parts of a given nerve. If 
* Yulpian, p. 104. 44 
INJURIES OF NERVES. 
now we remember that electricity travels at a rate of 
462,000,000 feet per second, we shall see how difficult it 
is to assimilate these two modes of motion. As regards 
reflex impressions, the difficulty is still greater, because 
most of these move slower than the excitations which 
cause voluntary motions, and are often so much retarded 
as to he capable of estimate by far coarser means than 
those employed by Helmholtz and Donders. 
I shall elsewhere have occasion to point out, when 
studying nerve injuries, how this question of the rate at 
which nerve force moves may come to possess practical 
value in determining the possible seat of the originating 
lesion. Just now, the matter has only thu§ much of in- 
terest. In certain pathological spinal conditions thejspeed 
of nerve force is so strikingly lessened as to be cabbie of 
rough estimate by a metronome beating quarter seconds. 
In some instances, this slowing reaches at least live sec- 
onds,—a degree of retardation which no alteration of 
conductors will enable us to realize as regards electrical 
currents. So that if we had only this fact as to relative 
speed, it alone would oblige us to believe that these two 
forces are absolutely distinct, and that they possess only 
such relationships as exist among the other natural forces. 
The conclusions thus reached are sustained by the later 
researches of Marey, who, however, puts the rate of nerve 
force at about half of that assigned to it by Helmholtz. 
He also sees in these facts an argument against the 
unity of nerve and electric force, but remarks that Gau- 
gain has shown that electricity in passing through moist- 
ened threads has so low a rate of movement as to make 
him still hesitate concerning the question of possible 
identity. In another place I have pointed out the need 
for some such experiments on bad conductors with elec- 
tricity of low tension; but the problem can only be 
definitely settled by a careful determination of the rate NEURO-PHYSIOLOGY. 
45 
at which the nerves themselves act as electrical con- 
ductors. At present the weight of evidence, as I have 
said, is opposed to the idea of the oneness of these two 
modes of motion. 
The property of being excited, which, following Lewes, 
Vulpian calls neurility, is common to all nerves. Sensitive, 
motor, reflex, nutritive, or sympathetic filaments, all alike 
have one and the same property, with no greater difference 
than exists between the physiological properties of differ- 
ent muscular tissues. 
There seems, indeed, to be every probability that how- 
ever aroused and whenever, in sensitive or motor nerves 
the vis nervosa does notvary in its nature. As regards the 
nerve fibres themselves, it is likely that their anatomical 
similarity, which is very great, whatever be their func- 
tion, represents a greater likeness in physiological effects 
than would at first sight seem possible. We are well 
aware that the sensitive and afferent nerves when irri- 
tated or normally stimulated seem to carry messages only 
in a centripetal direction, while of motor nerves the 
reverse holds true. There are, however, many facts 
which tend to show that irritation of any portion of 
either a motor or sensory nerve is propagated alike in 
both directions, central and peripheral, so that the nerves 
only appear to carry messages in one direction, because 
only at one end is either set provided with organs which 
have the power to announce the reception of an impres- 
sion. It is probable, therefore, that if in any nerve of 
mixed function we could suddenly connect the sensitive 
fibres with the motor centres at one end and the muscles 
at the other, that we should still have these latter effect- 
ively called into play, while of the motor fibres a like 
statement would hold equally good. 
This view, which might for a long while back have been 
sustained on theoretical grounds, has received positive 46 
INJURIES OF NERVES. 
evidence in its favor through the recent experiments of 
Vulpian and others. 
To settle the question, MM. Vulpian and Phillipeaux 
cut across the hypoglossal (motor nerve of the tongue); 
the central portion was then plucked out with its bulbous 
roots, next the pneumogastric was in like manner divided, 
and a long piece of the peripheral end excised, after which 
its central end was brought by suture in contact with the 
peripheral end of the cut hypoglossal. 
A post-mortem inspection after four months showed 
complete union and restoration of the neural integrity ; 
but, previous to this examination, pinching of the central 
parts of the pneumogastric caused free movements of the 
tongue; there "was, therefore, perfect communication of 
excitations from the central end of the pneumogastric to 
the peripheral end of the hypoglossal. The effect was 
the same when the pneumogastric had been divided a 
little way above the line of union; what remained of the 
nerve was still able to conduct impressions to the muscles 
of the tongue, and under this modification of the experi- 
ment all possibility of deception through reflex action was 
cut off. 
In like manner, when to the peripheral end of the pneu- 
mogastric is united the central end of the hypoglossal, 
irritations of this latter nerve influence the heart’s move- 
ments. In these instances it is clear that the impressions 
passed in directions exactly the reverse of those which 
they would usually follow, if the original function of the 
nerve determined and limited the direction possible to 
nerve force. Still more decisive are the cases in which 
the lingual nerve (sensitive) and the hypoglossal (motor) 
are united ; for here it was possible, according to the' mode 
of union, to excite motion through a sensitive nerve, or 
sensation through a motor nerve. 
There is, then, as Yulpian states, no histological distinc- NEURO-PHYSIOLOOY. 
47 
tion between motor and sensory nerves. Excitants affect 
either. Their electrical condition is alike. Toxic agents 
only seem to influence them differently because they act 
variously upon the parts, muscular or ganglionic, which lie 
at their extremities. Their degenerations and regenera- 
tions present no distinct difference, and both are capable 
of carrying messages in either direction.* 
Not less interesting and demonstrative are the cases in 
which M. Bert has grafted the tip of the rat’s tail into the 
dorsal region, and after a time cut the tail off at the 
normal point of attachment. A year subsequent to this 
operation irritations of the end of the tail were felt as pain, 
so that its sensitive nerves, now in union with dorsal nerves, 
must have carried impressions in a reverse direction. 
Where the central end of the lingual and the outer end 
of the hypoglossal nerves are united, it is found that irri- 
tation of the lingual causes pain and tongue movements 
at one and the same time. The excitation is, in this case, 
propagated in both directions, so that it would seem as if 
in all cases of nerve irritation or excitement the impres- 
sion affects the nerve from end to end, precisely as hap- 
pens when a stretched cord is made to vibrate throughout 
its length by a force applied to any portion of it.f 
This remarkable fact which has now been set in the 
clearest light by the experiments just related, as well as 
by the previous results obtained by Dr. Du Bois-Reymond, 
is full of interest to the pathologist as well as to the phys- 
* Vulpian, op cit., p. 286. 
f We may also illustrate the case by a tube open at one end, and having 
a whistle at the other. Blow into the centre of the tube and the air 
moves in both directions, but as it emerges it makes a sound only at the 
end possessing.a whistle, so that a careless observer would say that the 
air moved only in one direction. We pinch the trunk of a motor nerve 
and the muscle moves, but if at the other end of the nerve there were 
also a muscle, we should in like manner be able to see it brought into 
action. 48 
INJURIES OF NERVES. 
iologist. Hor is it possible to read these proofs without 
perceiving that as an irritant affects a nerve from end to 
end, and excites it in both directions, important results 
for nutrition may ensue if this irritation be extreme and 
long continued. 
Irritants applied along the track of nerves cause in the 
sensory nerves sensation ; in the motor nerves, motion. 
Where a mixed nerve is divided, stimulation of the periph- 
eral end occasions motion only, while the like agency 
applied to the central end produces pain. Under these 
circumstances, the other and varied forms of sensation 
felt during health are not distinctly reproduced, pain alone 
being present. 
If, however, the nerve ends, having been allowed to 
cicatrize without union, should be constantly irritated, as 
by imprisonment in the hard tissues of stumps, or scars, 
or by neuritis, a great variety of peculiar sensations are 
felt, such as the feeling of being tickled, of motion in the 
lost or disconnected part, heat, cold, etc. These facts, 
to which I shall have occasion to return, seem at least 
to prove that the physiological conception of the need for 
some peculiar peripheral arrangements for the production 
of touch, sense of movement, and the like, is without firm 
physiological foundation. 
A host of facts similar to these has led to a knowledge 
of the law of the reference of sensations, by virtue of 
which irritations along a nerve trunk, or of the centrally 
connected end of a divided nerve, give rise to sensations 
which are inevitably referred to the parts to which, in 
the normal state, this nerve was distributed. A knowl- 
edge of this law, and of the anatomical arrangement of 
nerves, is, of course, essential to the clear understanding 
and diagnosis of neural injuries, and a want of such 
knowledge has led, in certain cases, to operations as 
grave as amputation, for the purpose of relieving pains NEURO-PHYSIOLOGY. 
49 
which had their true cause in the upper end of a divided 
nerve. 
Neural stimulants.—The various forms of irritation which 
may affect the nerve trunks are capable of classification, 
and their character and mode of action are not devoid of 
interest to the neuro-pathologist. Laying aside the voli- 
tional stimuli, and those which result from the action of 
external agencies on sensory nerves, we shall find in disease 
another set, which may affect like those just mentioned, 
not alone the extremities of nerves, whether central or 
peripheral, but which may attack the nerves either in these 
localities or in their passage to and from the tissues with 
which they are functionally related. To this set of irrita- 
tions belongs inflammation, with all its consequences of 
increased temperature, swelling, and defective nutrition. 
Disturbed mechanical relations of tissues to nerves, tumors, 
cicatrices, dislocations, or fractures, may all come to act as 
irritants to neighboring nerve trunks, as well as the near 
passage of missiles, the presence of foreign bodies, wounds, 
etc. From these varied causes result numerous sensations, 
such as numbness, so called, formication, burning, itching, 
and, most prominently of all, pain in its endless variations. 
The physiologist has studied a class of nerve irritants 
which have, for the pathologist, only an occasional in- 
terest. These are electricity, heat or cold directly applied 
to nerve trunks, desiccation, excess of water and chemical 
agents, such as salt, sugar, bile, acid, etc. 
The first of these may be set aside for future study. 
Our information on these subjects is due chiefly to Eck- 
hardt, Budge, Kolliker, Kiihne, and Bernard. The first 
of these authors pointed out the power possessed by com- 
mon salt to excite, without destruction, the nerves of 
motion; so that when a divided peripheral end is placed 
in a concentrated solution of this agent the muscles are 
seen to contract; no such result being attained by weak 50 
INJURIES OF NERVES. 
solutions. Kuihne has described like effects from the use 
of glycerine; but the two reagents ditfer in this respect, 
that salt in strong solution acts convulsively on both 
nerve and muscle, but glycerine on nerves alone, except 
it be diluted with water, when it influences both nerve 
and muscle alike. Solutions of certain acids appear also 
to possess this property, while others, or stronger prepara- 
tions of the same, destroy the power of the nerve to act 
further. 
The most interesting of the substances thus capable of 
exciting the nerves are undoubtedly the acids, for 
it is to these, as Budge and Kiihne have proved, that we 
must assign the capability of the bile itself to evoke 
neuro-muscular spasms, a quality upon which some very 
extraordinary hypotheses have been founded. 
In all probability many of these agents act by subtract- 
ing from the nerve its water, and thus, finally, abolishing 
for a time one of the conditions of its active physiological 
life; for, as has been repeatedly shown, the function of 
the nerve may be restored by carefully allowing it to 
reabsorb a supply of this essential element. 
These studies have led to certain useful conclusions. 
Thus, when we see a nerve preserving its conductive and 
excitative abilities, despite the corrugation and apparent 
injury of the medullary portions of its structure, we have 
some right to infer that in the unaltered axis cylinder 
alone lies the capacity to convey impressions. Vulpian 
has also shown that sensitive and motor nerves are alike 
acted upon by these reagents; a proof added to the rapid 
accumulation of facts leading to a belief in the unity of 
construction and of mode of activity of the various orders 
of neural conductors. 
The manner in which nerve trunks and their extremities 
in the periphery are acted upon by the excess of water, 
or its abstraction, is one of larger interest to the neuro- NEURO-PHYSIOLOGY. 
51 
pathologist. As concerns the individual nerve, the facts 
are as follows: 
When a nerve is placed in a dense solution of certain 
salines it is at first excited, and then finally loses its func- 
tional powers, which may again be restored by placing it 
in water. 
If a nerve be slowly and carefully desiccated to a certain 
degree by warmth, or mere exposure to the air, it is ex- 
cited for a time so as to convulse its connected muscles, 
and at last ceases to be irritable until moistened anew. 
On the other hand, when we place nerves in distilled 
water, they lose their capacity to be excited, but regain 
it again when the balance is restored, by soaking them in 
weak solutions of phosphate of soda. Indeed, so delicate 
is the status of the nerve, so easily is it disturbed, that 
mere separation from the centres, or exposure short of 
perceptible desiccation, modifies the excitability of the 
fibres. 
We have thus learned that every modification in the 
amount of water, either towards desiccation or towards 
excess, tends to alter, and finally to abolish, the neurility 
of a nerve, while a restoration of the aqueous supply, or 
a loss of fluid by the water-soaked nerve, will, in either 
case, suffice to restore its function. 
As I have previously said, these are purely physiological 
experiments, and nothing akin to them is seen in man, ex- 
cept by rare opportunity in wounds exposed to improper 
dressings, or on the surface of ulcers. At first thought 
it might seem as if conditions of anaemia or hydrsemia 
offered some analogy to that one of the conditions just 
now described as an oversupply of fluid to the nerve; 
but in hydraemia, the pathological approach to this state, 
there are probably more complex changes in the nutritive 
supplies besides those arising from a too fluid blood. 
The opposite condition is best represented among diseased 52 
INJURIES OF NERVES. 
states by cholera, where the fluids are rapidly expelled 
from the system by purging and vomiting, until the blood 
becomes thick and of almost tarlike consistency. It 
seems not unlikely that the terrible cramps and pains 
of this malady may be due to this condition of the fluids, 
since in the individual nerve an excitation, resulting in 
spasms, follows always the drying of its tissues. 
Far more interesting are the neural phenomena which 
occur from absolute diminution or loss of blood or from 
the various degrees of excess of that fluid. 
When from arterial emboli, or owing to the ligation of 
a main artery, the blood is for a time cut off from a limb, 
its loss is followed in many cases by excessive pain, and 
more rarely by cramps. As Vulpian has justly remarked, 
the preponderance of sensory phenomena in these cases 
is due to the fact that the organ of final reference for 
irritations, the brain, is unaltered, whilst the muscles 
suffer early a loss of irritability, which deprives the motor 
nerves of all means of expressing the excitations to which, 
in common with the sensitive filaments, they are sub- 
jected. 
Examples of the pain produced in a limb by tying its 
great artery are familiar to surgeons; but I believe the 
phenomenon is not a constant one. In a case of ligature 
of the aorta by Mr. James,* the pain thus caused was 
terrible, nor did careful examination of the body furnish 
any explanation of the fact. It is at all events instructive, 
as concerns the causation of neuralgia, to learn that the 
lack of blood supply may be a condition productive of 
such extreme torture. 
As regards emboli in main arteries, I do not think the 
pain a constant symptom, but it is sufficiently common, 
and in more than one case within my own experience, its 
* Med.-Chir. Trans., vol. xvi. p. 17. NEURO-PHYSIOLOGY. 
53 
presence and severity have been the first indications which 
called attention to the arrest of local circulation by clot. 
Instances of venous occlusion differ somewhat in being 
less entire, and also in the increased rather than the 
diminished pressure which they bring about. 
Undoubtedly, the nerves are excited under these cir- 
cumstances, but the cause of their excitation does not 
seem to be very clear. Brown-S6quard attributes it to 
the gradual collection of carbonic acid in the tissues; but 
there are other elements of disintegration which may not 
be incompetent to disturb the nerves, and his hypothesis 
has found less acceptance than might have been expected 
from the really strong arguments which its author has 
adduced in its favor. Vulpian, on the other hand, is dis- 
posed to consider the absence of oxygen as more likely 
to occasion these excitations,—a view which certainly has 
less to recommend it than that of the former physiologist. 
Perhaps the causation may be more complicated than has 
been suspected, and at all events the sudden annihilation 
of nutritive osmoses and the novel conditions of pressure 
cannot be excluded from our enumeration of possible 
causes of pain, especially when we remember that all 
the neural phenomena of health are carried on in the 
presence of a certain varying but definitely limited press- 
ure, alteration of which, in the brain at least, is a fertile 
source of mischief. How far these pressure conditions 
may be needed for the proper functional life of the nerve, 
we can hardly surmise; nor can we, in any case, separate 
their probable influence from that of the nutritive supply, 
which varies with them and ceases when they no longer 
exist. 
That sudden alterations of pressure may alone be suffi- 
cient to painfully excite the nerves, is seen when a tourni- 
quet is removed after having been some hours on a limb. 
Such a treatment was resorted to, many years ago, for the 54 
INJURIES OF NERVES. 
purpose of controlling cramps or hysteroid attacks. I 
have heard patients who had been subjected to it speak 
of the sensations accompanying the return of blood into 
the limb as agonizing. 
The facts here related, as to the excitability of nerves 
by acids and alkalies, with the probability that much 
more dilute solutions would in man cause perceptible 
sensations for the existence of which in the animal we 
have no test, naturally leads us to speculate upon the 
share in producing or increasing pain which may be due 
to chemical alterations in diseased tissues. 
In nerve injuries, as I have already pointed out, the 
changes in surface secretion which give rise to over-acid 
or acrid sweats, may be paralleled by like chemical dis- 
turbances in the interstitial products of the nutritive 
processes, and from these may directly originate new 
sources of pain and of disturbed or diminished sensation. 
Probably, in this way, we are to account for the stiffness 
and pain which follow intense fatigue, and which most 
likely are due to accumulation in the tissues of the 
material products of disintegrative change. 
Influence of heat and cold.—The effect of heat upon 
nerves, when these are exposed to the air, is to desiccate 
them, and therefore to produce the symptoms already 
mentioned as due to desiccation. 
The effect of extreme cold upon the nerve centres was 
studied experimentally by the author in 1866 and ’67; 
and the special influence of this agent upon nerves was 
examined with care by Dr. Richardson, of Loudon, in 
1867, both making use of the spray producer invented 
by the latter observer. 
When a nerve is rapidly frozen by ether or rhigoleue 
spray, spasms are caused at first in its connected muscles, 
but in all classes of nerves the conducting power dimin- 
ishes, until finally, when absolutely frozen, it no longer NEURO-PHYSIOLOGY. 
55 
responds to volitional or electrical irritations ; and all the 
sensitive parts to which it is distributed become devoid of 
feeling. As the nerve thaws again, all of its functions 
gradually return. Altered vascular conditions also occur. 
At first the cold contracts the vessels, and almost instantly, 
as the part thaws, they dilate, and the part becomes the 
seat of a more or less intense congestion,—a circumstance 
of which I have made use in studying the congestions ot 
nerves and ganglionic centres. 
The best clinical study of the influence of cold on 
nerves was made by Dr. A. Waller,* in 1862. I shall 
have occasion to refer to it again. 
* Proc. Royal Soc. London, vol. ii. 1860-62, p. 89 et seq. CHAPTER IV. 
PHYSIOLOGICAL PATHOLOGY OF NERVE LESIONS. 
In the different forms of mechanical injury of nerves, 
a certain share of functional loss depends upon the cutting, 
tearing, stretching, or bruising of nerve tubes which the 
missile or weapon occasions. To this set of incapacitating 
causes are soon added, in varying degrees and at more 
and more remote periods, congestion, inflammation, and 
sclerosis, so that the remote pathological consequences 
are very often more serious than the primary hurt. 
Because, in the study of symptoms and of the varieties 
of nerve lesion, it becomes difficult or impossible to dis- 
cern what are due to mechanical interference, and what to 
the sequent pathological states, it is desirable to view these 
latter separately, and also to study the process by which 
an isolated nerve alters (degeneration), and that by which 
in time it is repaired (regeneration). For whatever so 
affects the nerve tubes as to annihilate their power to 
carry impressions, whether this be mechanical, as a wound, 
or a pathological state, such as inflammation or sclerosis, 
inevitably dooms them to a gradual change, which results 
first, in their partial destruction, and possibly, after a time, 
in their more or less complete repair. 
Congestion of nerves.—Our clinical knowledge as to the 
congestion of nerve trunks is so very limited that were 
we asked to define the symptoms which indicate its exist- 
ence, few pathologists would be ready with an answer. 
Yet there can be little doubt that such a condition does 
often exist, and that upon this pathological state, which 
(56) PATHOLOGY OF NERVE LESIONS. 
57 
disappears with death, may depend some of the neural 
maladies which we are as yet forced to style functional. 
Any effort to lessen our ignorance on this subject should 
be indulgently received, and I have, therefore, felt justified 
in setting forth the following observations, incomplete 
though they be. 
When by any method we freeze or even chill the living 
tissues, the act of thawing is followed by more or less 
congestion. The nervous tissues are no exception to this 
law, and whether in brain, spine, or nerve trunk, conges- 
tion is sure to follow the return of warmth, and to occa- 
sion which vary with the neural region attacked. 
The changes of tissue, immediately due to the process of 
congelation, have probably but little to do with these se- 
quent conditions, because the symptoms in question hold a 
relation in time and severity to the amount of visible con- 
gestion, and arising with it are most intense when it is at 
its height. By means, therefore, of chilling and thawing 
a nerve, I have been able, as I believe, to produce con- 
gestion with great certainty, and thus to study in man its 
associated symptoms, and in animals the pathological 
traces which it leaves upon the nervous tissues. 
The sciatic, the pneumogastric, and the sympathetic of 
the neck were, in animals, the nerves chosen for the pur- 
pose of pathological study. To effect congestion, no form 
of cold is so well fitted as that which, profiting by Dr. 
Richardson’s atomizer, I have myself introduced among 
the methods of physiological and pathological research. 
When a jet of ether spray, or of rhigolene, which Dr. H. 
J. Bigelow first employed, and which I greatly prefer, is 
thrown upon the skin, as the part thaws the vessels be- 
come paralyzed, and a spot of deep congestion is left, 
which lasts, in my own case, for twenty-four hours or 
longer. The effect is still more striking when the mem- 
branes and tissue of the spinal cord are attacked. The 58 
INJURIES OF NERVES. 
visible vessels then abruptly enlarge, new ones come into 
view, and the part obviously darkens.* 
Precisely the same effects follow when we freeze a nerve, 
and this is the case whether we protect its tissue from the 
chemical influence of the rhigolene or act upon it directly. 
I have usually preferred to cover it with thin rubber, or 
with a layer of some neighboring tissue. In some in- 
stances the nerves were frozen once, and examined after 
half an hour. In others the freezing was repeated once 
or several times, at intervals of hours or days. 
When a single brief freezing has been effected, there is 
usually a distinct congestion, which very soon lessens, and 
at all events leaves behind it no changes which can be 
seen under the lens. In more prolonged freezings, or 
when these had been repeatedly employed, distinct lesions 
were visible, and even to the unassisted eye the nerve 
looked darker, and in some cases larger, than was natural. 
Sections of nerves in this condition exhibit a seeming in- 
crease in the number of vessels, as well as frequent vas- 
cular ruptures, which dot the nerve with interfibrillar 
clots; while in some cases, long lines of red mark where 
the escaping blood has followed the areolar interspaces 
between the grosser divisions of the nerve. Cases as 
grave as this are not merely congestions, but actually apo- 
plexies of the neural tissue, and show their influence in 
the animal used, by lameness, and sometimes by distinct 
lessening of sensation in the parts to which the congested 
nerve is related. Of course the minor symptoms of sen- 
sory disturbance are incapable of study in the animal. 
* In the spine, as in the nerve trunks, sudden loss of power is the 
primary result of freezing, then follows a rapidly-increasing congestion, 
which is marked, in the case of the spinal cord in birds, by certain epilep- 
tiform phenomena of a very instructive character. 
See Am. Journ Med. Sci., Jan. 1867, and Jan. 1868, for my own re- 
searches on this subject. PATHOLOGY OF NERVE LESIONS. 
59 
When animals, the nerves of which have been subjected 
to extreme congestion, are allowed to survive, the lame- 
ness usually lessens and disappears ; but if, at the close of 
two weeks, the animal be sacrificed and the nerve sub- 
jected to study, it is common to find that, owing to the 
pressure of the minute clots above described, or to other 
causes, a certain number of the nerve fibres are under- 
going the Wallerian degeneration. 
If we subject the ulnar nerve of man, at the elbow, to 
extreme cold, we shall have certain phenomena, due to 
the suspension of nerve function, which will be followed, 
as the cold is removed, by a group of symptoms which 
it seems to me we have every right to look upon as caused 
by the sequent congestion of the nerve, and which, indeed, 
can scarcely be referred to any other cause. 
I had myself made several experiments upon the symp- 
toms which follow congelation, when I became acquainted 
with Waller’s admirable research. The following state- 
ment is therefore based upon his experiments and my own, 
which closely agree. 
I have repeatedly chilled or frozen the ulnar nerve in 
myself with ice, or ice and salt. The first effect is to cause 
intense aching pain, which, although most severe in the 
little finger, the outside of the third finger, and the ulnar 
palm, is also felt in the whole hand, and especially on the 
back of the hand, at the space between the metacarpal bones 
of the thumb and forefinger. The pain rather suddenly 
ceases at a certain stage of freezing, and for a moment 
the hand feels natural. Then the ulnar distribution in 
the hand begins to be numb, and this increases until all 
sensibility is lost,—touch, pain, and the thermal sense 
disappearing in turn. Last of all, motility, which very 
early is slightly affected, lessens by degrees, and is lost 
altogether. Soon after the part grows numb the ther- 
mometer rises slowly, sense of heat is felt in the ulnar 60 
INJURIES OF NERVES. 
palm, and this region, in my own case, sweats excessively. 
At the same time, the ulnar nerve at the elbow grows 
very excitable, and the least tap on the nerve causes slight 
pain in the third and fourth fingers, and sudden flexion 
of the first phalanges of all the fingers save the first, as 
well as adduction of the thumb. 
The average rise of the thermometer in moderate chill- 
ing, which does not annihilate sensation and leaves motion 
but slightly impaired, is 2° F. In more complete freezing, 
it is in my case from 3° to 4° F. 
The symptoms which follow the thaw are, as I believe, 
due chiefly to congestion. The nerve remains sore at the 
elbow and even some distance below and above it, while 
the brachial plexus may become tender (Waller), and as 
the thawing occurs, the heart may be enfeebled and syn- 
cope threaten (Waller) or vertigo occur, as I have felt 
in my own case. The terminal distribution of the nerve 
suffers, after severe freezing, for hours or days, so that 
soreness of surface, numbness, prickling, and partial loss 
of power may continue, together with a certain fullness 
which is felt and which makes itself visible to the eye. 
Even after slight freezing, there may remain for hours 
certain uncomfortable sensations which scarcely admit 
of distinct description. In one instance these symp- 
toms endured for eleven days, according to Waller, and 
in my own case they usually lasted from ten to fourteen 
days. 
We may therefore conclude, without being thought 
hasty, that numbnels, hypersesthesia, slight prickling, 
formication, and more or less loss of motility are the 
symptoms of congestion of a great nerve trunk. Tem- 
perature affords us no aid, as it becomes equal in all parts 
of the hand soon after the freezing is over. Such a com- 
bination of symptoms in clinical experience should teach 
us at once to explore the whole nerve track with care, in PATHOLOGY OF NERVE LESIONS. 
61 
order to tind, if possible, a spot where the nerve is tender 
on pressure, and where we would have a right to infer 
that there might be a local congestion which could be 
relieved by proper treatment. 
Neuritis.—Neuritis is in man one of the most common 
consequences of nerve wounds, and we might suppose 
from this that it would be always easy to produce it in 
animals by experimental interference with nerves. In 
some of the lower animals, such as the dog, upon which 
Dubreuihl made his observations, such inflammations 
may be produced, but not with any great ease or cer- 
tainty ; for although in one animal a caustic or a seton occa- 
sions more or less neuritis, in others this result altogether 
fails us, while it is also exceptionally rare to bring about 
in these creatures any well-marked sclerosis. 
In animals such as the short-eared rabbit, it is difficult 
to produce neuritis by any plan of dealing with a nerve. 
After numerous experiments, I succeeded but once, and 
unfortunately did not see the animal again until too late 
to study its neuritis in the active stage. It resulted in 
the formation of a number of abscesses within the sheath 
of the nerve. The nerve fibres in a degenerated state were 
found passing over the outer walls of the abscesses, and 
the resultant neural change passing upward had invaded 
the spine, causing sclerotic alterations of the same lateral 
half of the cord. 
Acute neuritis. — This disease is probably of extreme 
rarity as an idiopathic affection. It occasionally arises 
from wounds or from the inroads of cancer. I recall a 
terrible instance of the latter causation in a lady who 
died after horrible agony from pelvic carcinoma. She 
suffered from intense pain in the regions to which the 
sciatic nerve is distributed; the pain being remittent,— 
increasing at night. The sciatic nerve was exquisitely 
tender, and a distinct redness of skin accompanied its 62 
INJURIES OF NERVES. 
track half-way to the knee. After death I found the 
softened nerve lying in the pelvis behind a cancerous 
mass. Exterior to the pelvis it was swollen, red, and vas- 
cular to a remarkable degree. 
I have seen sudden and violent neuritis set up in an 
unhealed nerve wound, but have had no chance of exam- 
ining such cases pathologically. 
Symptoms.—The symptoms of acute neuritis as it is 
seen to follow upon a nerve wound are these: At some 
time between the reception and the healing of the wound 
the patient is attacked with rigors, which are not usually 
very severe. In the only case in which I have studied 
the temperature, the chill came on at noon, owing to a 
wound of the right median nerve received a week before, 
and followed by exposure in an open car during a journey. 
At four p.m. the rigors still continued, and at this hour 
the right axilla* gave a temperature of 102|° F. Fever 
came on in the night, and continued with evening exacer- 
bations for three days. With the rigor there was, in 
this case, a gradually increasing pain, which seemed very 
soon to pervade the whole limb. In four cases of which I 
have notes, there was slight delirium, owing as much to 
the horrible pain as to any other cause. In fact, some of 
these cases become what in a womau we should call 
hysterical, and by turns bewail their condition, or piti- 
fully apologize for their want of manly endurance. The 
pain seemed to be worse at night, and to be aggravated by 
motion and by a dependent position. In three of my cases, 
all arm wounds, it gradually increased both in severity 
and in the extent of the region affected, until it seemed 
to influence not merely the nerve first injured, but all the 
cords of the parent plexus. In one man there were, on the 
second day, sympathetic pains in the fifth nerve of the 
* The left was the same. PATHOLOGY OF NERVE LESIONS. 
63 
same side, and slight stiffness with severe pain in the 
muscles at the back of the neck. In one of my cases 
there was a distinct band of red overlying the nerve and 
running upward from the elbow, the site of the wound, 
into the axilla. In the remainder this symptom was ab- 
sent. Two cases had been carefully examined beforehand 
without finding any notable tenderness; but in these as 
in the others, not only was the nerve tender on deep 
pressure or on rolling it, but the skin above its track 
was sore, and during the second or third day the whole 
limb was hypersesthetic; while in two at least the sense of 
touch, already impaired, was notably diminished in acute- 
ness by the attack. 
In only one was there sudden and marked oedema 
within three days, and this case presented, a week later, 
one of the best examples of neural arthritis I have ever 
met with. 
Terminations.—Cases of acute neuritis are said sometimes 
to terminate early in resolution, without mischief to the 
nerve ; but in no case within my experience has this hap- 
pened. Usually the inflammation lessens, the fever sub- 
sides, and the pain diminishes, but does not altogether 
disappear. At last we have the nerve passing into a state 
of subacute inflammation, which may last for months, or 
not, as it is well or ill treated. 
The following histories may serve better to illustrate 
the clinical features of acute neuritis than any more 
methodical details : 
Case 1.—Dubreuilh* relates a very clear case which fol- 
lowed upon the excision of a tumor overlying the brachial 
plexus. The mass was adherent to these parts, and con- 
sisted of a sac full of hydatids and serum, which were re- 
moved, and then the mass dissected out. The usual 
* Nevrite, p. 104. 64 
INJURIES OP NERVES. 
antique French charpie dressing to excite suppuration 
was employed. On its removal, at the fifth day, a sharp 
pain began to be felt in the plexus, and, gradually increas- 
ing, became intense. There was high fever, insomnia, 
and headache. The median nerve was hard, enlarged, 
and exquisitely tender throughout, but especially high 
up. Over it the skin was deep red. The pain, which was 
constant, was made worse by movement. The forearm 
was swollen, and the fingers numb and feeble. The case 
was actively treated with leeches, venesection, and emol- 
lients, and, after a threat of erysipelas, which proved to 
be only an extension of the super-neural erythema, the 
case was discharged, well, at the twenty-fourth day. 
There were no after-consequences. 
The following example is less striking and was also less 
fortunate: 
Case 2.—J. C., sergeant, consulted me on account of loss 
of power in the arm, with severe neuralgia. At Gettys- 
burg he received a ball wound in the left neck, splintering 
the clavicle and emerging through the trapezius. Some 
fragments of bone were lifted out of the wound, which 
did well until a week later, when, on the way to Wash- 
ington, he was suddenly taken with a chill, of some 
severity, followed by high fever. At the same time the 
whole arm began to ache, darting pains shot up and down 
it, and the skin on the inside of the arm, below the axilla, 
was seen to be red. The nerve tracks were extremely 
tender. On the third day the whole arm was somewhat 
swollen, and the darting and aching pain was only sub- 
dued by frequent hypodermic injections. His first notable 
relief was obtained by an application of cut cups to the 
neck and shoulder, and gradually the pain lessened to 
its present grade of severity. The ulnar and median were 
hard, enormously enlarged, and very tender. J. C. de- 
scribed himself as having been made delirious by the PATHOLOGY OF NERVE LESIONS. 
65 
earlier pain of his disease; and even when seen by me 
after it had abated, he showed very plainly that the mind 
as well as the body had suffered,—his memory being im- 
paired, and his temper excessively irritable. This was a 
very good example of acute traumatic neuritis passing 
into the chronic form. 
Case 3.—L. P., a sergeant, was shot through the middle 
third of the thigh in the battle of Fredericksburg, and 
reached our wards within seven days. Whether the ball 
wounded the sciatic nerve or not was uncertain, but it 
must at least have bruised it, since there was some loss 
of power and of feeling. 
A small abscess in the walls of the wound of exit dis- 
charged itself with a fragment of clothing on the morning 
of the eighth day, and that evening he had a slight chill 
followed by fever and occasional rigors, lasting all night. 
There was sharp pain in the wound, and, before next 
morning, agonizing aching down the sciatic distribution, 
with intense burning in the foot. All next day the man 
was delirious, his face flushed, his pulse 130 and upwards, 
his tongue red and dry. He begged at times to be killed, 
at others, to go home; while sometimes he would lie open- 
eyed, regarding ferociously the passers-by who shook his 
bed as they walked, every movement seeming to add to 
his torment. On the third day the fever abated and his 
pulse fell. He said the pain was no better; but by this 
time he was quite unmanned, and his evidence was value- 
less. He would at this time, however, allow me to handle 
the limb, which he had, until then, refused to do. It was 
slightly swollen, bathed in profuse sweat, as it had been 
throughout the attack, and the nerve track was exquisitely 
tender; when, indeed, an assistant rudely pressed upon it, 
he shrieked with pain, and grew faint, pallid, and sick at 
the stomach. I could detect no band of redness over the 
nerve, but at two places, between the wound and the 66 
INJURIES OF NERVES. 
foot, there were very red spots. One of these was in the 
popliteal space, and one over the point where the peroneal 
nerve dips into the muscles. 
Under active treatment the pain lessened, but the foot 
became subject to severe burning, and it was many months 
before the patient recovered from the shock of this painful 
malady. From being a man of gay and kindly temper, 
known in his company as a good-natured jester, he became 
morose and melancholy, and complained that reading 
gave him vertigo, and that his memory of recent events 
was bad. 
Diagnosis and prognosis.—I do not see how this malady 
can well be confounded with any other, especially when 
it is the result of a wound. Its future must depend, to 
some extent, upon how soon it is recognized, how boldly 
and skillfully treated. It may pass away, as I have said, 
doing little harm, or, what is more probable, it may occa- 
sion subacute neuritis or sclerosis, or may be the fertile 
parent of neuralgia, causalgia, joint disease, and local 
palsies. 
Chronic or subacute neuritis.—This condition is a com- 
mon consequence of wounds of nerves, and is apt to 
follow amputations, but, though rare as an idiopathic 
malady, it is not excessively uncommon. It is brought 
on by cold or rheumatism, and as a result of acute neu- 
ritis, while only once have I seen it as a consequence of 
syphilis. 
Symptoms.—Subacute neuritis is often incapable of dis- 
tinct clinical discrimination when of a mild type, and 
when there is an absence of traumatic cause. In its fullest 
development it is characterized, as I have seen it, by the 
following peculiarities, which are best marked after it 
has existed for a length of time. The affected nerve is 
tender over a large portion of its track, and the points of 
emergence, from a bone or through a fascia, are still PATHOLOGY OF NERVE LESIONS. 
67 
more sensitive, while in true neuralgias it is only the 
points of Yalleix which are easily hurt by pressure. 
Moreover, unlike the hypersesthetic spots of neuralgia, 
the sensitive nerve tracks of neuritis are constant, and 
alike tender at all times. Some difficulty may arise 
where the neuritis is limited and lies near to a recent 
wound, the tenderness from which may be confounded 
with that of the nerve. 
In many old cases of neuritis, unless the nerve is small 
and deep seated, it can be felt as an enlarged and hard- 
ened cord, so that it is frequently easy to distinguish even 
the deeply placed sciatic nerve. 
The redness which may overlie an acutely inflamed 
nerve I have not seen in cases of chronic neuritis; but, 
when long continued, it is the cause of structural changes, 
such as atrophy of the skin, with causalgia, changes in 
the nails, oedema, and rarely of sclerotic thickening of the 
dermis. The pain of subacute neuritis is aching in char- 
acter, and less distinctly follows the larger nerve tracks 
than does that of neuralgia. Like neuralgia, it is, how- 
ever, liable to increase at night, and may even affect such 
returns of violence at fixed hours, although it is rather 
to be described as remittent than intermittent. 
Whatever quickens the circulation makes it worse, and 
movement always lights up the torture afresh. Indeed, 
so surely is this the case that absolute rest is indispensa- 
ble in the treatment. 
(Chronic neuritis has a constant tendency to pass cen- 
tripetally, and thus to involve new nerves; and this is so 
characteristic of neuritis and of sclerosis, whether the 
latter be of inflammatory origin or not, that in any trau- 
matic case where pain is found to be attacking in turn the 
various neural distributions arising from a common plexus, 
I should at once suspect the existence of an organic cause. 
A close search for the symptoms I have described will 68 
INJURIES OF NERVES. 
very often disclose the presence of an unsuspected neuritis, 
and I feel very sure that, far more often than is thought, 
some such condition lies behind very many of the cases 
of what we treat as sciatic neuralgia. 
Sclerotic alterations of nerves may possibly arise with- 
out the aid of neuritis, but this is at least doubtful; nor 
do I know any signs by which old chronic neuritis can be 
clinically diagnosed from sclerosis. 
It is surprising how great may be the apparent struct- 
ural change wrought by neuritis before the power to move 
is remarkably interfered with. The pain on motion of 
course limits motility, and may thus lead to error; but, as 
a rule, tactile sensation is more altered than motor power, 
and even the former may not sutler gravely until late in 
the case. Nearly always I have found, somewhere in the 
limb, liypersesthetic regions where a touch was more un- 
pleasant than deep pressure. The skin over the nerve 
trunk is apt to be thus affected, and when leeches are 
used on this part, their first effect is often painful, and 
they sometimes occasion an unusual amount of swelling 
and annoyance. 
Prognosis.—The future of any case of long-continued 
subacute neuritis is rather a dark one, and is grave in 
proportion to the length of nerve involved, and the extent 
to which it has traveled in a central direction; since if it 
has passed up as far as the parent plexus, so as to be 
beyond surgical reach, the case may usually be regarded 
as one to be relieved, but rarely to be cured. 
Pathological results of neuritis.—The primary effect of in- 
flammation of a nerve is to render it more vascular, to 
enlarge and increase its vessels, to cause an enormous 
development of its connective tissue elements, and at first 
to render the nerve less firm, owing partly to this hyper- 
plasia, and partly to an effusion of serum within the main 
sheath and between the nerve fibres. The secondary PATHOLOGY OF NERVE LESIONS. 
69 
consequences which may follow acute inflammation I 
have not seen in man, so as to be able to relate them clini- 
cally. Rokitansky has stated them concisely. The nerve, 
intensely injected in lines, is dotted with minute extrava- 
sations of blood, becomes cedematous, and at last firm, 
from a grayish or yellowish-red gelatinous fluid, which 
hardens soon or late, at the same time that the surround- 
ing tissues become involved, and present the ordinary 
inflammatory appearances. Should resolution occur, 
these products are slowly reabsorbed, and a gradual re- 
turn of function takes place. Higher grades of neuritis 
reduce the nerve rapidly to a gray or yellowish-red pulpy 
cord, for which the inflammation and the constricting 
sheath are together responsible. The nerve is then tender, 
and readily torn, and its tissue infiltrated with bloody pus, 
the color of the nerve becoming yellow or brownisli-red 
or chocolate tinted, while abscesses may form around its 
track. Ulceration is described as the final stage of this 
destructive process. 
"When the more acute inflammations pass into those of 
a lower grade, or when these alone have attacked a nerve, 
a series of changes result with which I am personally 
more familiar. 
The nerve trunk is then more irregularly vascular, and 
is enlarged in some places and smaller than it should be 
in others. The induration, which affects more or less the 
whole of the inflamed portions, varies in density, so that 
sometimes there is a long, firm swelling of an inch or more 
of nerve, or else in a part moderately hard there is a suc- 
cession of firm little fibroid bodies imbedded, and around 
them a circle of greater vascularity than elsewhere. The 
color of the nerve is usually some tint of gray or pale lead 
color, and in all probability the tact corpuscles undergo 
enlargement and degeneration. The tendency of these 
cases is usually towards hypertrophy and hardening of the 70 
INJURIES OF NERVES. 
connective structure of the nerve; and also, as a rule, the 
morbid change tends to march from extremity to centre, 
rather than outward. The result of these alterations is 
a gradual increase of connective white fibrous tissue, a 
consequent thickening of the sheaths, and finally, a more 
or less complete atrophy of the nerve tubes, involving 
chiefly the w7hite substance of Schwyann, and leaving the 
nerve fibre a mere rod, hardly to be distinguished from 
the more wavy fibrous tissue about it. This destruction 
is rarely complete throughout the nerve, so that nearly 
always nerve tubes in every state of health and degen- 
eration can be seen within the area of a single inflamed 
and hardened nerve. I have thus met with perfectly 
healthy tubes in a nerve which was as tough as a tendon. 
With every appearance of enlarging, such nerves are 
actually undergoing atrophic changes as to their proper 
tissues. 
Increase of bulk, proliferation of connective tissue, and 
wasting of nerve tubes are common consequences of 
chronic neuritis; but sclerosis may also be brought about 
without the intervention of inflammatory conditions, or, 
at all events, the change which began in these may in- 
crease and continue long after they have faded or dis- 
appeared. Sclerosis without inflammation undoubtedly 
occurs in the nerve tissues of certain stumps where their 
nerve trunks are enlarged and hardened, but neither 
tender nor neuralgic. I have recently seen with Dr. 
Mears a patient whose hand wTas removed by Dr. W. L. 
Atlee, on account of a remarkable train of symptoms, 
which, beginning with local spasms in this part, resulted 
in typical epileptic fits. The median and ulnar nerves 
were three times their natural size, and as hard as tendons. 
Besides an immense proportion of fibrous tissue and de- 
generated nerve tubes, there were still many of the latter 
in an uninjured condition. The tenderness over the PATHOLOGY OF NERVE LESIONS. 
71 
nerve tranks had been slight and remittent, nor was pain 
at all a marked symptom. This was probably a ease of 
pure sclerosis without inflammation. It is of course very 
difficult to decide as to. the absolute non-existence of the 
latter condition, but I have had every reason to believe 
that, in some nerve wounds, the resultant sclerosis had no 
connection with inflammatory states except at the very 
outset, and that the former, in many cases, made mischiev- 
ous progress without the latter. 
The final functional result is the same in either case. 
The nerve tubes in large part perish or waste, and the 
symptoms affect at first rather the sensory sphere than 
that of motility. We have pain and anaesthesia or hyper- 
sesthesia, but not as a rule local convulsions. 
These atrophic nerve changes, whether due to inflam- 
matory or sclerotic pressure, or to actual nerve section, 
demand a more careful and specific study, since upon 
a clear conception of their nature and the time they 
need for repair depends our success in the prognosis 
and treatment of a large number of local maladies of 
nerves. 
Treatment of congested or inflamed nerves.—I shall have 
frequent occasion to allude to this subject in treating of 
neural injuries, and to describe in detail the various means 
employed; but I have also thought best to give here a 
more methodical statement. 
Whenever, after an injury, such as a blow or wound 
involving a nerve, the nerve track in its near neighbor- 
hood begins suddenly to be acutely tender and painful, 
especially if rigors be added, it is well to take for granted 
the outset of a neuritis, which we should hasten to pre- 
vent from becoming acute. As I have said, my experi- 
ence of this malady, and, indeed, that of most physicians, 
is limited. In the only case of acute neuritis of which I 
had entire control from the start, the arm from above the 72 
INJURIES OF NERVES. 
wound to the finger ends was enveloped in bladders of ice 
and iced water, which certainly lessened the pain. The 
limb was elevated above the body, and fa gr. hypodermic 
doses of sulphate of atropia with i gr. of srriph. of 
morphia were given every four hours, or oftener, as 
needed. This plan, with attention to the secretions, 
seems to me sufficient. I have also used leeches very 
freely and with good effect, the ice being afterwards 
replaced. I should add that leeching is sometimes exces- 
sively painful, and that the leech bites are more apt to 
give trouble than in other cases. Absolute rest is one of 
the essential conditions of treatment, and if the limb can 
be put upon a rigid splint it is wise to do so. 
Chronic neuritis is generally subacute, and is one of the 
most difficult of all maladies to treat with success. It 
very often occurs in persons who are perfectly well able to 
walk about; and as it is vain to hope for good results with- 
out entire repose, the comparatively good health of the 
patient is a real obstacle, especially in the arm cases. 
Constitutional treatment—In the army it was above all 
things needful to look for the existence of scurvy or mala- 
rial disease, and to treat these with appropriate means, 
—dietetic and therapeutic. But under all circumstances, 
it is well to remember that the presence of such torture as 
accompanies this disorder of itself induces a lowered vital 
tone, which requires tonics and support, and that some- 
times the long use of opiates has a depressing effect, which 
we shall be wise not to forget. 
jRest—When the disease is really subacute, and the 
nerve tender on pressure for some considerable part of 
its length, I insist upon the most absolute rest. If it be 
the leg which is attacked, the patient must go to bed and 
consent to wear a carved splint for several weeks. If it 
be the arm, a splint answers to put it in a state of repose; 
and without this it is vain to employ other means. PATHOLOGY OF NERVE LESIONS. 
Cold should be used over the nerve track by means of 
Chapman’s spine-hags, or better, by such as are now made 
by the Davidson Rubber Company, which are thinner than 
those of English make. The caoutchouc bag should be 
inclosed in an outer case of thin flannel, and may then 
be kept in situ by the splint and a bandage, if a splint be 
worn. In most instances I have used these ice-bags over 
nearly the whole length of the main nerve, and have usu- 
ally contented myself with their employment in the day- 
time. In some cases, however, I have had them renewed 
twice in the night, and this plan I believe to be the better 
of the two. The only difficulty lies in the first pain from 
cold, and is easily overcome. The relief afforded is often 
remarkable, and the loss of the nerve in size, hardness, 
and tenderness most gratifying. 
Counter-irritants.—Revellents begin to be of use when 
the tenderness has lessened or only exists in a slight de- 
gree. I like best the revulsion caused by faradising with 
the wire brush (secondary current) the dry skin, well 
powdered, at a little distance from the line of the nerve. 
Vesication may also be used in the same situation,—but 
never over the nerve,—while more extensive irritation 
by Pearson’s plan I have also found useful; but as to 
all of these means I shall have to speak more fully when 
discussing the treatment of symptoms, which late in these 
cases sometimes assume so much importance. 
Sedatives.—Of hypodermic and other uses of sedatives 
I shall also have occasion to speak elsewhere. Let us use 
them freely, but be mindful of the fact that when reck- 
lessly employed they bring about moral and physical 
conditions which are simply fatal to successful treatment. 
For examples of the methods employed, and which I 
do not find insisted upon elsewhere, the reader is referred 
to the chapter upon the therapeutics of symptoms. 
Degeneration and regeneration of nerves.—The history of 74 
INJURIES OF NERVES. 
the subject of the wasting of nerves and of their repair 
presented no great interest until the classical researches of 
Augustus Waller, in 1862. This admirable observer has 
been happy in the almost perfect accord with which his 
researches have been met whenever they have been ex- 
perimentally examined by competent inquirers. Since a 
clear knowledge of his conclusions lies at the basis of the 
subject of nerve changes after section, I shall endeavor to 
give a brief and distinct account of these results. 
Section of a nerve trunk, whether it he sensitive, motor, 
or of double function, insures degeneration of the pe- 
ripheral extremity. If, however, we divide the sensitive 
filament (posterior root) of a spinal nerve between the 
ganglion and the spinal cord, the central end alters and 
the portion attached to the ganglion remains unchanged. 
Section of the motor (anterior) root, between the spine 
and its union with the posterior root, gives us degenera- 
tion of the external end and no alteration of the central 
extremity. Connection with the spine or the ganglion 
seems, therefore, to insure against degeneration the ante- 
rior or posterior root respectively. Waller himself believed 
that the ganglion is the trophic, or nutritive, centre for 
the posterior root, and that the gray spinal matter, in like 
manner, holds the same office for the anterior root. Phy- 
siologists have, however, hesitated to accept this theory, 
while the facts themselves have remained undisputed. 
Whenever section of a compound nerve has been made 
exterior to the ganglion, the entire peripheral end of the 
nerve alters, and the central end remains unchanged. 
To this law, Laverran* has pointed out a supposed ex- 
ception. In the central end of cut nerves he found a 
few altered fibres, and in the peripheral end, a certain 
number of sound fibres. The degenerating fibres of 
* Laverran, These de Strasbourg, 1864. PATHOLOGY OF NERVE LESIONS. 
75 
the central end represent, according to this observer, Ber- 
nard’s recurrent sensitive loops, which, being divided, the 
returning thread is thus dissevered from its trophic centre, 
the ganglion, and therefore becomes altered. In like 
manner, Laverran explains the unchanged fibres, in the 
exterior nerve end, as the recurrent fibres derived from 
neighboring trunks, through which the fibrils in question 
retain their connection with the nutritive centres. I have 
myself observed such altered nerve tubes in the central 
ends of cut nerves, but they were exceptionally rare, while 
in the outer ends I have failed to notice any sound tubes 
after the lapse of a certain time. 
The upper end of a cut nerve remains but little altered 
for a few days, after which a rapid proliferation of connec- 
tive tissue occurs, and there is a visible enlargement 
formed, which, if no reunion occurs, finally gives rise to 
the well-known button-like growth, which we shall have to 
study in connection with the neural maladies of stumps. 
The enlargement which follows simple section rarely 
attains such dimensions as it does after amputations. 
The peripheral end of a cut nerve undergoes inevita- 
ble alterations, as to the exact nature of which there has 
been some difference of opinion, so much so, indeed, that 
I have felt it necessary to study the subject experiment- 
ally before venturing to describe the changes in question. 
These researches were made chiefly on rabbits, young or 
old, and include examinations of the sympathetic, pneu- 
mogastric, and sciatic nerves. 
From the fourth to the sixth day after section, we ob- 
serve in the whole length of the peripheral end a slight 
alteration of tint, consisting in a loss of transparency. 
Laverran denies this, because, as he says, the removed 
nerve is never transparent. I am confident, however, 
that if a piece of healthy nerve be observed alongside of 
the altered nerve, a difference will be seen even as early 76 
INJURIES OF NERVES. 
as the sixth day. At all events, this change corresponds 
with the partial loss of excitability in animals. In man, 
the earliest total loss of power to respond to electricity 
which I have seen was on the seventh day. At or about 
this time the whole substance of Schwann begins, in 
birds, to undergo irregular segmentation, a process which 
is slower in dogs and rabbits. The double contour 
of the fibres becomes irregular at first, as though the 
myoline were indented more or less deeply. Then the 
segmentation grows more complete, and the outlines of 
the fibres more broken, so that the myoline is finally to 
be seen distributed along the sheath of Schwann in 
masses, which are round or elongated and irregular at 
first, but which, by the third to the sixth week, become 
smaller, more numerous, and rounder, so that, in most 
cases, at the close of three months, the nerve tube holds 
only the finest granular elements. More or less speedily 
this remnant of the white substance of Schwann disap- 
pears, and the sheath of Schwann becomes shrunken, 
and, as it were, wrinkled, the whole nerve being now 
distinctly of a dull gray tint, and looking like a firm 
bundle of connective tissue. 
When the ‘nerve has reached this final condition of 
degeneration, there are still present in the sheath here 
and there a few minute molecules of fatty matter, and 
occasionally such masses are also observed lying between 
the fibres. Laverran has noted at this period, within the 
sheath, certain minute collections of matter very slightly 
retractile, and which I have also noticed, though not con- 
stantly. They resemble, optically, colloid substance, or 
portions of escaped myoline. After this time, there does 
not seem to be any notable change in the residual sheath, 
except, perhaps, a slight shrinking, and in some cases an 
increase in the amount of interfibrillar fatty molecules. 
The alteration of the white matter of Schwann has been PATHOLOGY OF NERVE LESIONS. 
77 
described as fatty degeneration; but, as Robin has re- 
marked, it is largely fatty in the first place, and the 
alteration may consist only in its being broken up and 
removed, there being no evidence that any such substi- 
tution has taken place, as is found to occur in ordinary 
instances of fatty degeneration. 
The utmost difference of opinion exists as to the per- 
sistence of the cylinder axis during these progressive 
transformations of the nerve. The majority of observers 
incline towards belief in its permanence, and so far as my 
own researches are concerned, I am also of this opinion, 
although regarding it as a point most difficult of decisive 
settlement.* 
The degeneration has been described as passing from 
the centre to the periphery, but I am satisfied that it 
affects at one and the same time the whole length of the 
nerve. For although it is true that a current which, at 
the sixth day after section may not cause motion, when 
applied at the upper limit of the nerve, may still do so 
when used nearer to the muscles, this is due to the fact 
that in the former case it has to overcome the resistance 
offered by a longer track of altered nerve. 
If we ask ourselves why the nerve alters after division, 
several answers seem possible. The nerve may change 
because its function is abolished,—the central part of a 
motor nerve Tailing to alter owing to its being traversed by 
* The rate at which the nerve change occurs varies greatly in different 
animals, being rapid in birds, and slower in the rodents. In the frog it 
is most speedy in hot weather, and in the hibernating animals Schilf 
states that it is so singularly slow, that five weeks elapsed in the marmot 
with less change than five days produced in the dog. In the snapper, 
Chelonura serpentina, I found it to be equally tardy during the winter. 
Some years ago, in the autumn, I cut the left sciatic nerve in two box 
turtles, which soon buried themselves in my garden. On their reappear- 
ance in April, I found the nerves quite unchanged. Within the next 
month the peripheral end of the nerve underwent complete alteration. 78 
INJURIES OF NERVES. 
currents of central origin ; but this would only hold good 
of the motor filaments, and as regards the outer end would 
scarcely apply even to the sensitive fibres, which would 
continue to be excited from without, yet the whole of the 
external end changes, and none of the central extremity. 
Waller’s theory, which attributes the preservation of 
the central end to the conservative power of the ganglion 
for the sensory root, and of the spinal centres for the 
motor root, still remains the most prominent explanation ; 
but whether we are to hold, as he held, that these are, as 
regards the nerve, direct trophic centres or not, is still a 
matter of doubt. 
A few observers have been inclined to refer the changes 
which follow section to paralysis of the vaso-motors of the 
nerve concerned, but such an agency seems hardly com- 
petent, nor could we, admitting it, explain the automatic 
regeneration of isolated nerve ends. Whatever be the 
character of the neural impression which, setting out from 
spine or ganglion, preserves the nutritive integrity of the 
nerve to the remotest filaments, it must, in the case of the 
sensory branches, be propagated in a direction opposed to 
that in which they are traversed by impressions from with- 
out. It would follow from this, either that the preserva- 
tive influence exerted by the centres passes along special 
nerve fibres,—nervi nervorum,—or that the sensory fibres 
are capable of transmitting impressions both centrally and 
peripherally. 
The difficulty of explanation is increased, however, by 
the autogenetic restoration of nerves separated from the 
centres, and which I shall presently have to describe, and 
also by the repair of motor nerve ends when united to 
sensory nerves which still remain connected with the 
centres. As regards these points, M. Laverran states with 
Schiff that there are numerous trophic centres, and that 
very certainly the nutritive centre of one nerve may serve PATHOLOGY OF NERVE LESIONS. 
79 
a like end for another, and that perhaps by means of anas- 
tomoses, and after a certain lapse of time, the trophic centre 
of neighboring nerves may come to answer a similar pur- 
pose for the peripheral extremity of the divided nerve. 
Of this, however, we have no proof. We only know that 
completely isolated nerve ends ma}7 undergo repair with- 
out having, so far as we are aware, any connection with 
the centres. When, therefore, nerves are cut, the peri- 
neural covering, the sheath of Schwann, and probably 
the axis cylinder, rest unaltered, while the myoline or 
white substance of Schwann breaks up, becomes granu- 
lar, and disappears completely. 
Regeneration of nerves.—When the nerve has reached its 
final term of change, a new process begins, which may or 
may not result in its functional restoration. After a nerve 
has been divided, and a portion exsected, it either remains 
separated, or the two portions reunite with more or less 
completeness. In both cases the nerve fibrils of the 
peripheral extremity undergo a reparative change, so that 
we have two sets of conditions under which to study the 
progress of restoration. 
Within two months after section, the upper end of 
the nerve is seen to exhibit a slight enlargement, from 
which projects a grayish, conical bundle of delicate fibres. 
Many of these are normal in appearance, others want, at 
first, the medullary matter. As this stem extends to- 
wards, and finally reaches, the peripheral nerve end with 
which it unites, the fibres increase in number and in bulk, 
the complete fibres becoming more numerous as the tint 
of the new formation changes to the healthy white color 
of normal nerve tissue. After some months, it may ac- 
quire, what at least in my experience has been rare, the 
full size of the nerve ends which it joins together.* In 
* Vulpian, p. 256, op. cit. 80 
INJURIES 0E NERVES. 
small animals, as the rabbit, from two to four lines of lost 
nerve may thus be made up, and in man there are cer- 
tainly instances of at least three inches having been re- 
stored. 
While many of the peripheral fibres are still under- 
going destructive changes, and before the nerve ends are 
reunited, the process of repair begins in the lower end of 
the cut nerve, so that, in young animals, degeneration and 
regeneration are going on in separate fibrils side by side. 
Among the wasted tubules appear others, in which the 
medullary matter is replaced, and in this manner gradu- 
ally the atrophied nerve tubes undergo a process of repa- 
ration until the nerve is recomposed, the newer elements 
being smaller for a time than the original fibres. The 
change thus effected appears to go on alike at one and 
the same time in the whole length of altered nerve. 
Waller was of the opinion that the fibres thus formed 
were throughout new formations, but this view has been 
refuted by both Schiff and Vulpian, and there is now but 
little doubt that, they are merely restorations of the origi- 
nal tissue. 
Until the reuniting tissue contains a considerable num- 
ber of healthy filaments, and until the lower nerve end 
has undergone a large amount of restoration, the func- 
tions of the nerve remain in abeyance, and the question 
as to the time needed for repair, and of the extent of this 
process, are therefore of the utmost importance in con- 
nection with the prognosis and treatment of nerve in- 
juries. 
Autogenetic restoration of nerves.—Vulpian and Philli- 
peaux have shown that even when the divided nerve ends 
do not reunite, the peripheral extremity undergoes after a 
considerable time a more or less complete process of re- 
pair, precisely such as occurs when reunion has taken 
place. This reparation may occur even when a portion PATHOLOGY OF NERVE LESIONS. 
81 
of nerve has been transplanted and grafted upon foreign 
tissues; but although physiologically interesting, these 
observations have no practical bearing upon the subject 
of nerve wounds, except to show that the severed nerve 
does not so alter as to forbid in the future ahy operation 
looking to its reconnection by suture, or otherwise, with 
the parent stem. CHAPTER Y. 
VARIETIES OF MECHANICAL INJURIES OF NERVES. 
Serves, like other parts of the body, are subject to a 
great variety of lesions from physical agencies. In some 
cases these act without breaking the overlying skin, while 
in others the cut or wound involves the integuments so as 
to make what may be called a compound nerve wound, a 
condition involving, however, none of the added danger 
which an open wound brings to a broken bone. In fact, 
a clean cut through a nerve trunk is often far less grave 
than a contusion sufficiently severe to cause complete loss 
of power, or even, I might say, to produce less severe 
consequences. 
Direct lesion by a missile of war or by incision.—Gunshot 
wounds, and, more rarely, sabre cuts, are the most fre- 
quent injuries of nerves during war, and they may pre- 
sent every variety in degree of severity, from the slightest 
abrasion to absolute loss of considerable nerve substance, 
as was certainly the case in many instances of wounds by 
conical balls observed by my colleagues and myself at the 
U. S. A. Hospital for Nervous Diseases. With us, at least, 
and the same remark applies generally, sabre wounds 
and bayonet injuries were very rare. I have seen no nerve 
lesion from the latter weapon, and if we except scalp 
wounds involving nerves, only one from the sword. 
Seat of wounds.—The large number of wounds in the 
upper half of the body seen by us admit of the explana- 
tion that they bore transportation better than did those of 
(82) VARIETIES OF MECHANICAL INJURIES OF NERVES. 
83 
the legs, which involved usually far longer and more seri- 
ous ball tracks. Perhaps their frequency may have been 
due in part to the greater proportion of all wounds of 
the upper limbs. Lesions of the cranial nerves were 
rarely seen by us, because these injuries were so often 
accompanied by fatal results at an early date, owing to 
grave brain or face lesions. One wound of the sympa- 
thetic, the only one on record, and several of the seventh 
nerve, with one of the fifth nerve, complete the sum of 
our hospital experience in this direction. 
In the table of nerve lesions reported by Londe, and 
also in Hamilton’s cases, the proportion of injuries of the 
upper limbs is far larger than that of the legs; so that in 
civil practice as well as in war the nerves of the arms 
especially are most apt to suffer. 
Incised wounds of nerves.—In civil life the most common 
examples of nerve wound arise from thrusting a hand 
through a glass window-pane, both nerve and vessel being, 
generally, severed. I have seen one case of this kind, 
in which the ulnar nerve was divided without the artery 
being cut. Knife wounds and the like of course exhibit 
a variety of incisions of nerves, resulting in greater or 
less loss of sensation and of motor power as the division 
of the nerve is more or less complete. 
Amount of injury.—The extent of injury to a nerve is of 
course of the utmost importance, and is learned only by 
the most careful examination of the parts to which the 
nerve is finally distributed, in order to ascertain what 
movements are lost and what skin surfaces show defects 
of sensibility. 
I shall have occasion to treat more fully of this subject 
in connection with gunshot wounds of nerves; but even 
here, it will be well to notice certain points which, if neg- 
lected, are apt to lead us astray. Thus in studying loss of 
motion, we should remember how closely related are the 84 
INJURIES OF NERVES. 
regions of the hand, for example, and that many of its 
parts are stirred by more than one muscle or set of 
muscles. 
In examining the sensibility, too much care cannot be 
observed, since there is a natural instinct which causes us 
to use any power of motion we may have in order to press 
upon and so examine the touching body. Care as to these 
points, and minute attention to the anatomical distribu- 
tion of nerves, will usually decide the extent to which a 
nerve may have been divided, where the accident is a 
simple incision. Although there is a general impres- 
sion that a clean cut of a nerve, partial or complete, is 
likely to result in total restoration of function, I am sorry 
to state, as my own experience of such cases years after 
the accident, that the histories of entire restoration are 
sadly rare, and that most instances of divided nerves, if 
abandoned to themselves, result in deformities and func- 
tional losses such as characterize, though in far graver 
degree, gunshot lesions. I suspect that the experience 
of most physicians will support me in this 
which is amply sustained by Mr. J. Hutchinson’s* series of 
histories, nearly all of which were glass wounds, resulting 
in serious and lasting loss of sensation or motion, with 
marked nutritive changes. 
Among cases of this nature, of which I have seen 
several, but always late in their history, the burning pains 
are certainly more rare than in wounds by missiles, yet 
they are not altogether wanting, as Mr. Paget’s cases show. 
The two following examples may answer as illustrations 
of this class of injury and of the consequences which 
are apt to follow it. In these, as in other neural lesions, 
the nerve section is certainly followed b}7 the usual de- 
generation of the peripheral end, just as is seen in animals. 
* Clinical Lectures and Reports, London Hospital, 1866. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
85 
Whether in man autogenesis of this extremity occurs 
when the part remains isolated from the central stem, is 
as yet unknown; nor have we learned to what degree 
the defect of arterial circulation, which in one of the 
cases must have followed ligature of the ulnar and radial 
arteries, is capable of affecting the process of nerve 
repair. 
Case 4.—Section of median nerve ; abscess at the site of the 
wound; loss of sensation and motion. R. L., farmer, Dela- 
ware County, was brought to me by his brother, one of 
the former patients of our military hospital. Two years 
before he had been accidentally wounded by a reaping 
cradle, the point of the scythe entering the forearm and 
dividing the median nerve just below the elbow. Unfor- 
tunately the wound, which was closed with care, sup- 
purated freely at the third week, and an abscess-was 
opened alongside of the older scar. It is said that there 
was at this time some sensibility on the outside of the 
forefinger, but it disappeared soon after the abscess 
formed, and not the least sign of returning function was 
ever seen in any part supplied by the median nerve. The 
skin on the radial side of the palm was thick and rough, 
and the limits of loss of sensation absolutely distinct, 
while all the muscular dependencies of the cut nerve were 
in the last degree of atrophy and contraction. 
I proposed to my patient to cut down on the nerve and 
to bring the two ends together, when I hoped by galvan- 
ism to complete the cure, which, without the operation, I 
had failed to effect by prolonged faradisations. He de- 
clined to submit to the knife, and finally abandoned all 
hope of relief. 
I felt well assured that the suppuration in this case in- 
terfered with, and terminated, the early efforts at repair. 
The very slight skin changes in this history contrast 
remarkably with those of the following case: 86 
INJURIES OF NERVES. 
Case 5.*—Division of the ulnar nerve and vessels and of the 
median nerve ; anaesthesia of the parts supplied; inflammation 
of the tips of three fingers, unattended by sensation; diminution 
of animal heat in all the parts paralyzed; increase of heat 
during inflammation, but still not up to the normal standard.— 
“ A healthy girl, aged twenty-two, cut the ulnar side of 
her right forearm very deeply on a broken window-pane. 
The wound was at the upper part of the lower third, and 
passed across the ulnar vessels and nerve deeply into the 
mid-structure, probably dividing the median nerve. It 
bled very freely indeed. She was taken to the hospital, 
where the hemorrhage was arrested and the wound dressed. 
“ She came under my notice three weeks afterwards, the 
wound being then just healed. The scar was puckered 
in. She stated, as regards pain, that she had had very 
little in the wound, but much aching in the palm. 
“ The hand of the wounded arm looked a little thinner 
and a little paler than the other, but there was no other 
difference to the eye. All the fingers were kept bent 
slightly in the palm, and she was unable to straighten 
them, owing, as she believed, to the effort to extend 
dragging on the scar. In the attempt to extend, the scar 
was moved. She was able to flex the fingers fairly, 
but could not contract her palm or bring the thumb into 
apposition with any of the fingers. The muscular mass 
between the thumb and forefinger was thin and flabby. 
The beat of the ulnar artery could be detected below the 
scar. 
“ Sensation.—Immediately below the scar she could feel 
the prick of a pin, but not acutely; an inch or two lower, 
she could scarcely feel it. To the radial side, and at all 
parts above the scar, she could feel well. At the level of 
the wrist, in front, all sensation was lost, excepting over 
* Hutchinson, op. cit., p. 314. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
87 
the ball of the thumb, where it was retained in an imper- 
fect degree. The little finger had no sensation on either 
side, nor had the ring, middle, or forefingers. There was 
no sensation at the backs of the little, ring, and middle 
fingers; very little at the hack of the forefinger, but 
somewhat more behind the thumb. Over the hack of the 
hand, sensation was imperfect, being more so as the ulnar 
border was approached. The extremity of her ring- 
finger was inflamed, and presented an open sore, on the 
face of which, however, the prick of a pin was not felt in 
the least. The ends of the middle and little fingers were 
also inflamed. She had had no pain during the forma- 
tion of these whitlows, hut a continued aching in the 
palm of the hand. The palm, it should be observed, was 
not in the least swollen, nor was it tender to pressure. 
“Nutrition.—About ten days after the accident, the tips 
of the little, ring, and middle fingers inflamed. In each 
the exact tip was affected, and serum was effused beneath 
the skin over the entire extremity; the finger-ends were 
slightly swollen, reddened, and, in the case of the ring- 
finger, somewhat tense. Ho pain was felt. The effusion 
in the little finger was absorbed. The skin at the end of 
the ring-finger died over the space of the size of a six- 
pence, and there is now an open sore at that part. On 
the middle finger, the subcutaneous bulla still exists. 
The cuticle is elevated by effused serum (subcuticular 
whitlow), and there is an areola of reddened skin about it. 
“Temperature.—On cursory examination, no difference 
from normal heat would have been observed in the 
affected hand (the weather being sultry). On compari- 
son with the other hand, a difference is, however, very 
perceptible; the nails of the affected hand feel, indeed, 
slightly cold. By the thermometer, a difference of about 
nine degrees is shown between corresponding parts of the 
two hands. On the finger most inflamed, the heat is 88 
INJURIES OF NERVES. 
greater than in the others, hut still does not rise quite(to 
that of the same finger of the other hand.” 
Eight forefinger (paralyzed), side, 79°; front, 78° 
Left “ (sound), “ 90 “87 
Eight little finger (paralyzed), labial side, 80 ulnar side, 79 
Left “ (sound), “ 89 “ 89* 
Eight ring-finger (paralyzed, but inflamed), front, 89 “ 89 
Left “ (sound), 89 “ 91 
Eight middle finger (paralyzed, but slightly inflamed), 89 “ 87J 
Left “ (sound), 89 “ 91 
Lancet wounds of superficial nerves.—In civil practice, it 
was common at one time to meet with injuries of the 
musculo-cutaneous or the anterior branch of the internal 
cutaneous nerves, the result of lancet wounds in bleeding. 
One of the earliest reports of such injuries is Ambroise 
Pare’sf brief account of the case of Charles IX., who 
suffered from a nerve wound thus described by his 
attendant: 
“ Or pour instruire le ieune Chirurgien, et le dresser 
rnieux a la pratique dessusdite, ie reciteray ceste histoire, 
qui n’est hors de propos pour la curation des piqueures 
des nerfs. 
“Le Roy ayant la fieure, monsieur Chapelain, son pre- 
mier Medecin, et monsieur Castelan, aussi Medecin de sa 
maieste, et premier de la Royne sa mere, luy ordonnerent 
la saignee: et pour la faire on appella vu qui auoit le 
bruit de bien saigner, lequel cuidant faire ouuerture a la 
veine, piqua le nerf; qui fit promptemeut escrier le Roy, 
disant auoir senti vne tres grande douleur.” 
Contraction of the muscles followed, with continued 
pain, and during three months the king could neither flex 
nor extend the arm; hut, nevertheless, was in the end 
happily cured. 
* The sides exactly alike. 
f GEuvres completes, ed. Malgaigne, t. ii. p. 115. Paris, 1840. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
89 
Abernethy,* Mr. Swan,f Hamilton,! and others relate 
numerous instances of such accidents with more or less 
disastrous consequences than chanced to Fare’s royal 
patient. These are in many respects among the most 
curious histories of nerve wounds with which I am ac- 
quainted, and would lead us to suspect that more exten- 
sive reflex symptoms are likely to be aroused by wounds 
of small cutaneous nerves than by those of larger trunks, 
and perhaps also that certain central conditions are needed 
to determine the grave symptoms which in numerous cases 
of slight nerve wounds are altogether wanting. 
Nowadays these injuries are so rare that in my own 
experience I can recall but two, both of which date back 
several years, so that for instances of this nature we must 
resort to the older treatises. 
Mr. Swan has detailed a number of slight wounds in- 
volving small nerve branches. In some of them there 
was instantly acute pain in the track of the nerve distri- 
bution, which speedily subsided, while in others it grew 
more severe, until general convulsions resulted. In certain 
cases the pain began after some hours, and rapidly in- 
creased, with the addition of hyperEesthesia, fever, local 
twitchings, and general convulsive disorder, which in 
very rare examples assumed an epileptic type.§ 
It is principally notable in these histories that the 
gravest symptoms were due to wounds of small filaments, 
few instances of like severe symptoms having followed 
those of great trunks; a fact which accords, as I have 
said, with what we now know of the larger capacity of 
nerves for evolving reflex phenomena as they approach 
* Surgical and Physical Observations. London, 1793. 
f Swan, op. cit., p. 110. 
| Hamilton, Jr., Dublin Journ. Med. Sci., March, 1838. 
\ Swan, case, p. 117. 90 
INJURIES OF NERVES. 
sensiti ve surfaces. Moreover, the greater number of such 
cases were women, and the hysterical element comes 
largely into view as the disorder progresses. 
The following case from Swan* may answer as an illus- 
trative example: 
Case 6.—“I was desired to visit Mr. B.’s housekeeper 
at . I found my patient in strong convulsions, and 
held upon the bed by several assistants; her hands were 
strongly clinched, and she was struggling greatly; she 
soon after became comatose. I was informed that she 
had been let blood two days before by a gardener; that 
she complained very much of the arm where she was 
bled, and of a pain shooting from thence to the shoulder. 
“I examined the orifice of bleeding, which was in the 
median veins ; it had not healed, was somewhat inflamed, 
and a thin liquor oozed from the lips of the wound. 
While I was making this examination she became again 
strongly convulsed, as I supposed, from the irritation I 
had caused. With a view to interrupt the communica- 
tion from the diseased point to the seusorium, I applied 
a tourniquet above the part; a remission of the spasms 
soon followed, and I administered an anodyne; but the 
convulsions, after a short interval of ease, recurred as 
before, and the application of the tourniquet was again 
made without any good effect. As I had no doubt that 
the cause of the disorder was an injury of a cutaneous 
nerve in the operation of venesection, I determined to 
endeavor by a transverse incision to divide the nerve 
above the injured part, and to destroy its connection with 
the sensorium; I therefore made an incision while the 
convulsions were most violent, of about an inch in length 
and small depth just above the orifice: no mitigation of 
symptoms was perceived; but on making another incision 
* Swan, op. cit., p. 121. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
91 
above the former one, somewhat deeper and longer, she 
cried out immediately, to the astonishment of the attend- 
ants, ‘I am well, I am quite well; I can stir my arm 
which she began to move, and continued to do so with 
great delight for some time in various ways. She had no 
return of the spasms, and very soon got well.” 
Slight injuries of the digital nerves seem especially 
prone to occasion distressing symptoms and to awaken 
widespread reliex sympathies. Mr. W. M. Banks* has 
recently reported several cases of this nature, for which 
Mr. Bickersteth removed portions of the affected nerves 
with excellent results. No lesion of the exseeted portion 
could be discovered. The Paccinian corpuscles were 
probably increased in number and size,—an observation 
not elsewhere made, but deserving of remembrance in 
future examinations. 
Punctured wounds of nerves.—If we include only those 
histories which strictly deserve the name, punctured 
wounds are excessively rare, but are apt to be followed 
by very serious accidents, owing to secondary changes in 
the nerve, and occasionally also by grave constitutional 
disturbances. 
As I have before remarked, some additional element in 
the way of a tendency towards neural malady seems to 
be essential to these and to the cases of lancet cuts result- 
ing in serious symptoms; because it is only in rare 
cases after all that we meet with the consequences in 
question. Thus in bleeding it was common enough to 
cut a small nerve and see no result save a limited numb- 
ness which gradually faded away, while in animals I have 
always failed to excite any of the symptoms so dreaded, 
by causing punctures of nerves, nor has it been found that 
the wounds caused by acupuncture are to be greatly 
feared even when purposely involving nerve trunks. 
* Liverpool Medical and Surgical Beports, Oct. 1869, vol. iii. p. 73. 92 
INJURIES OF NERVES. 
M. JBerard has described a ease of true puncture of a 
nerve which may be taken as a typical example. For 
certain galvanic experiments, he passed a needle into the 
supraorbital nerve. The electric current was then sent 
through the nerve, causing great pain, which soon passed 
away, to return again and again, until it took on a quotid- 
ian type, which yielded for a time to quinia, but recurred 
at intervals with great violence.* 
I saw many years ago, in Paris, a man in Prof. Roux’s 
wards who had driven an awl through the ulnar nerve. 
Excruciating pain followed, with choreal twitchings of 
the flexors of the fingers, which in the end gave way to 
spasm. I believe that the case was finally relieved by ap- 
plications of the actual cautery along the nerve track. 
The passage of a needle into the nerve of an animal 
causes usually a little intrafibrillar bleeding, which passes 
away without grave result. Berard describes punctures 
as occasioning inflammation and final thickening of nerves. 
He quotes Descot to like effect, but I have been unable 
to find that this author makes any such statement regard- 
ing simple punctures. 
Contusion; pathology.—The only pathological study, and 
that a brief one, of bruised nerves has been made by Til- 
laux, who subjected nerve trunks to slight blows from a 
hammer, and then examined the injured part. He found 
that the neurilemma remains unbroken, but that numer- 
ous hemorrhages occur within the main sheath, and that 
the blood gliding along between the fibres may pass to 
some distance beyond the part affected. 
Lesser collections exist even within the perineural 
sheaths, and traverse, in places, the intervals between the 
broken nerve tubes. At the seat of injury, many of the 
fibres are lessened in calibre, and beyond it, on either 
* La Nouvelle Encyclographie, 1846, p. 37. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
93 
side, nerve tubes are seen irregularly dilated, and present- 
ing the usual alterations in calibre which are observed in 
nerve bundles teased out for microscopic study. Three 
or four days later but little effort at repair is visible, and 
at the point struck the nerve tubes seem to be lost 
in a granular mass. Below the contusion, they present 
the appearance of granular fatty degeneration, with the 
well-known coagulation of the medullary sheath. Til- 
laux’s account is thus far perfectly correct. In like inju- 
ries which I have followed up in rabbits, the so-called 
fatty alteration of the nerve progressed exactly as in cases 
of section, save that it was more or less complete as the 
original injury was more or less destructive, many fibres 
in the latter case escaping change altogether. 
I was impressed, however, with a fact which finds 
ample clinical illustration. In some cases where I struck 
the nerve smartly with a smooth, broad whalebone slip, 
allowing a thin layer of muscle to intervene, the paralysis 
which ensued, although often temporary, was in degree 
complete. In these instances there was usually little 
hemorrhage, but a few fibres were torn, and a large pro- 
portion suffered simply a mechanical disturbance, which 
gave them for the time a baccated look and irregularities 
of outline, due to displacement of their semi-fluid con- 
tents. If a nerve, disturbed only to this degree, be ex- 
amined within a few days, when the paralysis is no longer 
discernible, the nerve tubes present but very slight traces 
of mechanical alteration, and a still later inspection rarely 
shows greater alteration of the nerve save in a very few 
fibres. 
It is therefore probable that the condition described is 
one which is for the most part rapidly repaired, and that 
the temporary symptoms which follow slight nerve con- 
tusions may be due to the definite mechanical disturbance 
here spoken of. 94 
INJURIES OF NERVES. 
More severe lesions break the fibres, and subject the 
entire tubes to the pressure of multiplied clots of blood 
and to the destructive effects of compression by the ma- 
terial poured out for purposes of repair. 
In two of these cases artificially produced in the rabbit, 
the nerve trunk became considerably enlarged, so as in 
one case, at least, to be fitly described as a neuroma. 
Symptoms and results of contusions.—Contusion of nerves 
is a common incident of civil practice. In military 
experience contusions are met with arising from the 
impact of fragments of shell or entire round shot, and 
are of course sufficiently grave in their results, whether 
the skin be broken or not. I have seen in the United 
States Hospital for Nervous Diseases, and elsewhere, a 
number of instances of contusions from blows, kicks, or 
falls, some of them slight in character, and others causing 
the most entire crushing of the nerve involved. As a 
rule, a blow with any blunt instrument over the length of 
a nerve is unlikely to be serious; but when the same 
injury falls upon the nerve at its exit from a bony fora- 
men, or where it rests in a furrow of bone, or lies super- 
ficially on the prominences of a joint, the consequences 
may be much more severe, as I have already pointed 
out, when speaking of certain wounds in relation to the 
spinal nerves at their points of exit from the interverte- 
bral foramina. 
As a rule, contusions, unless violent, do not cause im- 
mediate symptoms of loss of function. A little numb- 
ness and tingling may succeed to the first shock of pain, 
and only after a time be replaced by grave troubles, as 
changes by-aud-by occur in the bruised nerve; changes 
only too apt to result in evils quite as permanent as those 
which arise from more immediate injuries. I have several 
times met with bad cases of atrophic alterations of mus- 
cles, the result of a contusion of a nerve, which for some VARIETIES OF MECHANICAL INJURIES OF NERVES. 
95 
time after the injury gave few signs of latent injury. 
Some such evidences of hidden mischief do, however, exist 
in nearly every case, and should be taken as indications 
for anticipative measures of treatment. Considering the 
number of nerves exposed to this form of injury, it is 
surprising that it is not more frequent. The nerves, how- 
ever, yield somewhat to sudden pressure, and roll aside 
with great readiness, so that, except when they are firmly 
hound to a bone, it is not easy to hurt them with any 
weapon except one which possesses a blunt surface. 
I have seen the supraorbital and infraorbital both con- 
tused by a single blow from the head of a cane. The 
lower nerve suffered most, and it was some months before 
the parts to which it runs regained sensibility. 
The slighter results of blows on the ulnar nerve behind 
the elbow are within every one’s experience, and occasion- 
ally this nerve is so injured as to involve permanent results. 
I saw, some years ago, a singular instance of this, which 
arose during play between two lads who were striking 
each Other with knotted ropes. One of them, in pro- 
tecting himself, threw the elbow upward and outward, 
receiving a severe blow upon the ulnar nerve, thus stretched 
and held steady by the bent elbow. The tingling pain 
soon passed away, but in the course of the third week an 
attack of measles resulted in the return of pain and tin- 
gling in the ulnar distribution. These assumed a distinct 
intermittent type, became very violent, and were at length 
relieved by placing the arm at rest in half extension on a 
splint and by the use of morphia subcutaneously. 
Causard,* Descot,f Hamilton,J and Duchenne all report 
cases of contusion of more or less interest. Examples are 
* Essai sur la Paralysie suite de Contusion des Nerfs. These de Paris, 
1861. 
f Affections locales des Nerfs. Paris, 1825. 
% Arch. Gen. de Med., 1838, t. ii. 96 
INJURIES OF NERVES. 
also to be found in the work of my colleagues and myself, 
and two very illustrative histories, one of a blow on the 
neck and one of a contusion of the musculo-spiral, are 
related in the Sanitary Commission Reports.* 
Case 7.—David Frauklyn, aged twenty-two. In October, 
1820, was seen by Mr. Swan. Seven years before, he was 
holding a restive horse by a halter wound tightly around his 
hand and wrist, when the animal, running back, drew the 
halter tight, and bent the wrist, pulling on it violently. 
Great pain ensued in the hand and wrist, and continued 
ulceration of the dorsal skin of the hand followed. The 
thumb and three fingers were bent back towards the wrist, 
and so remained, there being loss of sensation and of touch- 
sense. Mr. S. amputated the hand, and found hypertro- 
phy of the median beneath the annular ligament, and 
several gangliform enlargements of the digital nerves.f 
Case 8.— Contusion of right brachial plexus ; pain; consequent 
loss of motion in the deltoid muscle ; toasting ; cure by electricity ; 
rheumatism, a year later, with renewed neuralgia and weakness ; 
final relief. Mrs. K., aged fifty-two, fell and struck the 
right side of her neck against one of the round knobs of 
a brass fender. There was early swelling, and also a good 
deal of pain felt in the right arm for a few minutes, owing, 
as I supposed, to violence done to the brachial plexus. 
In a few weeks the blood extravasated at the spot struck 
was absorbed. Slight pain was, however, felt in the fore- 
arm and hand at intervals, until the twelfth week, when it 
became extreme around the shoulder-joint. Next came 
loss of motion, and wasting in the deltoid, with increase 
of tenderness at the site of the blow. Leeches were freely 
used every third day at this point until the soreness dimin- 
ished, when I blistered the part twice. The shoulder pains 
were now lessening, and at the fourteenth week I began 
* Medical Reports, 1867, p. 412. 
f Swan, op. cit., p GO. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
to use hypodermic injections of one-eighth grain of sul- 
phate of morphia with one-fiftieth grain of sulphate of 
atropia. Under this treatment, employed daily, she lost 
all pain, except when the arm was moved. I made two 
efforts to faradise the deltoid, but each time caused in- 
crease of pain. At the fifth month I was able to resort to 
the battery, under the use of which the muscle gained 
bulk and power very rapidly. After twenty sittings, she 
could raise the arm outward to an angle of 43°. 
A year afterwards Mrs. K. had an attack of inflamma- 
tory rheumatism, which left her with distressing neural- 
gia of the ulnar distribution chiefly, and with some weak- 
ness of the forearm. 
This attack was treated by leeching, blistering tender 
points in the nerve, and absolute rest of the member, a 
measure which I have sometimes found of the utmost 
value. The arm finally remained feeble, and the pain is 
now, a year later, so rare and so slight as to give but little 
annoyance. 
A very interesting case of contusion of the ulnar nerve 
will be found among the cases at the close of the chapter 
on Treatment. 
Injuries to nerves from dislocations or their reduction.—One 
of the most interesting forms of contusion is that of the 
axillary plexus in certain dislocations of the humerus. In 
considering this accident, it will be convenient at the same 
time to treat of the less common palsy caused by the re- 
duction of the displaced bone, and due most probably to 
laceration or stretching of a nerve more or less fixed or 
anchored by inflammatory processes in the surrounding 
parts. 
Some slight degree of nervous disturbance is liable to 
show itself upon the reduction of any old dislocation of 
the head of the humerus into the axilla. I have seen sev- 
eral such patients, whose arms had been replaced by the 98 
INJURIES OF NERVES. 
late Prof. Miitter after considerable lapse of time, and in 
all the reduction was followed for some weeks by pain, 
numbness, and muscular feebleness. What is here exem- 
plified in a mild form is more gravely illustrated in two 
cases reported by Flaubert.* In one of them a complete 
palsy of the arm followed reduction, and, upon examination 
post mortem, “the four lower nerves of the axillary plexus 
were found to have been torn across.” In his fifth case, 
the traction being more moderate, the paralysis is con- 
ceived by him to have been due to a simple elongation of 
the nerves involved. 
Desaultf and other surgeons report histories of palsy in- 
stantly following reduction, or coming on within a few days 
afterwards, but none of these equals in interest the casej 
of a soldier, whose right arm was reduced on the day 
of the displacement with instant production of brachial 
paralysis without pain, and yet with permanent reflected 
anaesthesia and paralysis of the right neck and with ptosis 
and partial loss of sight of the right eye; The forearm 
and hand were also insensible. 
The risk of nerve injury apparently increases with the 
previous duration of the luxation, but even an early re- 
duction sometimes brings about paralysis. In a case which 
Duchenne§ relates, the palsy is stated to have been caused 
by the reducing process; yet, on careful reading, there 
seems to be no reason to suppose that it may not have 
been produced by the accident, which preceded the reduc- 
tion by only two days. Where the remedial measure is 
applied as soon as or earlier than this, it often happens that 
* Rep. d’Anat. et de Phys., 1827. I take this reference from Causard, 
having been unable to get the Repertoire, and I am also largely indebted 
to his Thesis for statements in regard to this subject, 
f CEuvres compl., t. i. p. 355. 
J Mem. de la Soc. de Biologie, 1854, p. 119, E. Le Bret. 
\ De l’Electrisation localisee, p. 190, 2d ed. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
99 
no careful examination has been made as to the nervous 
condition, so that when, after reduction, the arm appears 
paralyzed, the surgeon is apt to refer it to the last disturb- 
ing cause, and not to the accident. 
Dislocation causing nerve injury.—That dislocation of the 
humerus should sometimes cause paralysis is not surpris- 
ing, since even a severe blow upon the shoulder is compe- 
tent to this result, as every surgeon well knows. Cases 
of this nature are related by Causard, and I have faradised 
two patients for injuries thus produced. 
Without following further the classical discussions upon 
this accident, it will be sufficient to state the opinions 
which I have reached after careful examination. 
In the first place, falls on the shoulder or on the hand 
being competent to cause palsies of the arm, we may ex- 
pect to meet with the latter even in such cases of disloca- 
tion as put out of the question any possible compression of 
nerves by the head of the humerus. In dislocation of the 
humerus backward, a rare accident, no nerve lesion is 
likely to occur. In luxation downward into the axilla, 
the capsule is of course torn, the muscles and tendons are 
bruised and elongated, and the circumflex nerve, extremely 
liable to injury from its close relation to the capsule, is very 
apt to be torn or stretched. This latter lesion, which has 
been actually found post mortem, is the cause of the atro- 
phy of the deltoid which sometimes ensues. Hamilton 
thinks that the muscular loss is often due to the mere 
contusion of the deltoid; but on the whole it is more in 
accordance with modern views to see in the atrophy a con- 
sequence of nerve lesion, of which rheumatic or scrofulous 
inflammations of the joint are so apt to furnish examples. 
In dislocations of the humerus under the coracoid pro- 
cess, or under the clavicle, the circumflex nerve and the 
muscles about the joint are prone to suffer severely, while 
the brachial nerves are liable to be carried forward with 100 
INJURIES OF NERVES. 
the head of the bone, and to meet with injury, the amount 
of which is determined the force with which the head 
of the bone breaks loose from the glenoid cavity.* 
Mr. Hilton has described a dislocation downward 
into the axilla, in which the humerus, although reduced 
with ease, was retained with difficulty. At the thir- 
teenth week the man died from disease of the chest, when 
the circumflex was found to have been torn and dis- 
placed. I have seen a case in which, after a dislocation 
easily replaced, the deltoid wasted, and then other mus- 
cles suffered, while neuralgia of severe type accompanied 
the nutritive changes. Here the pathogenesis was, no 
doubt, injury to the circumflex, atrophic alteration of the 
deltoid, centripetal propagation of the neural changes, 
secondary alteration of other branches of the brachial 
plexus, and consequent neuralgia and muscular atrophies. 
In grave cases of injury to the nerves during disloca- 
tion, they are compressed, as Helatonf has pointed out, 
between the clavicle, the flrst rib, and the head of the 
dislocated bone. The degree of paralysis probably de- 
pends upon the violence employed in the displacement 
being sufficient to drive the dislodged part against the 
tissues which lie on its inner side. The theory of direct 
contusion is now generally held to explain the observed 
results, and but one author, Empis,J has ottered any other 
explanation than that which I have given. He reports a 
case in which a man luxated his shoulder by a fall, and, 
thirty-six hours later, before its reduction, was seized with 
loss of power in the arm muscles without the least defect 
of sensibility. Puzzled by this coincidence, he otters, in 
explanation, the theory of the muscles having lost their 
* Hamilton, p. 561. 
f Elem. de Pathol, chir., t. v. p. 170. 
J Empis, These de Paris, 1850. M. Debout also attributes these palsies 
to contusion of the muscles,—a strange conclusion. VARIETIES OP MECHANICAL INJURIES OF NERVES. 
101 
irritability owing to some undetermined pathological 
cause. It is, of course, quite possible that there may 
have been here a co-operative spinal palsy, limited to 
nerves of movement; but he does not show that the mus- 
cles were at all insensible to electricity; and, as regards 
the mere fact of there being only motor palsy and no sen- 
sory loss, it may be added that this is a common incident 
of nerve wounds of all kinds, as I have elsewhere shown, 
and as I shall have occasion to point out more at length 
in future. 
The essays of Malgaigne and Duchenne are so full of 
cases of palsy from dislocations as to make it needless to 
quote all the instances I have seen. The three histories 
which follow may suffice as illustrations. 
Case 9.—Dislocation of left humerus from a fall; reduction 
in twenty-four hours ; at the fourth week general loss of power ; 
atrophy and contractions ; rapid cure by electricity. A soldier 
fell from a tree, striking and dislocating the shoulder so 
as to displace the left humerus, in what direction is not 
known. It was replaced within twenty-four hours, and, 
the previous pain and numbness disappearing, he remained 
well for four weeks, when the arm began to waste, 
with loss of power, which became complete in a few 
months. Sensation was much less altered. At the close 
of a year, we found him with only partial ability to flex 
the arm, and with slight use of the flexors and extensors 
of the fingers. Marked atrophy also existed, with con- 
traction of the pronators. Rapid relief and final cure 
were obtained by electricity. In this case there was 
plainly some trouble at the time of dislocation, and the 
resulting difficulties were due to secondary changes in the 
brachial plexus. As a rule, such cases are readily amen- 
able to treatment. 
The following very instructive case was sent to the Hos- 
pital for Deformities and Hervous Diseases, by Prof. D. 
II. Agnew: 102 
INJURIES OF NERVES. 
Case 10.—Dislocation of humerus into right axilla ; no loss 
of sensation ; instant palsy of arm and hand; gradual relief; 
reduction in third week; palsy of extensors of wrists and fingers; 
very slight sensory loss. C. B., German, aged fifty-one; well 
and vigorous; upholsterer. Fell six weeks ago from a 
height of six feet, and, striking the right elbow, threw the 
head of the humerus into the axilla. There was no pain 
except in the shoulder, neither was there, he insists, any 
marked loss of feeling; hut the hand was paralyzed, semi- 
flexed, and, he says, stiff and numb. After three weeks, 
Dr. Agnew reduced the dislocation and placed the limb 
at rest in a sling. During the two days which followed, 
there was pricking in the ulnar region of the hand, which 
ceased upon the removal of the bandage. 
Present state, June 23, 1871.—Shoulders alike; right 
arm somewhat wasted; greatest circumference of right 
forearm, nine and seven-eighths inches; of left, ten 
and one-fourth inches. No tenderness above or below 
clavicle over nerves, except that the musculo-spiral was 
a little sensitive to pressure. The hand experiences 
a general burning, but no darting pain; sensation is 
scarcely impaired; feels warmer to the patient, and 
sweats unusually. The muscles above and below the 
elbow are flabby, and quiver even when not in action, and 
the arterial pulsation is remarkably violent. The biceps 
acts well, as do the other arm muscles. Pronation is 
good; supination is chiefly accomplished by the biceps, 
the supinator longus being feeble. The fingers and thumb 
flex well, but their extensor power is partially lost, as well 
as abduction and adduction. He has slight power to ex- 
tend only the second and third phalanges of the first and 
second fingers, less of the third, and none of the fourth. 
Extension of the wrist is entirely absent. 
Temperature of right palm is . . . . . 96f° F. 
“ “ left palm is 97f° F. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
103 
The flexors of the forearm, hand, fingers, and thumb 
move well when acted upon by induced currents. The 
common extensors and those of the hand respond feebly, 
as do all the interosseal muscles, save the fourth, which 
scarcely stirs under any current. The abductor of the 
little finger has no electro-muscular contractility. The 
electro-muscular sensibility is good everywhere except in 
the interossei. 
Ordered faradisation thrice a week, from which resulted 
immediate and rapid improvement. The case is still under 
treatment. 
The remarkable loss of motion, with the very slight 
affection of sensation, makes this case rather notable. 
When admitted, there was certainly no appreciable defect 
of the touch- or pain-sense, and no neuralgia or burning 
after the first days of his case. Neither was there the 
least disease of the joints. The following history of a 
similar accident is interesting on account of the presence 
of some of the symptoms which were wanting in C. B., 
as well as the fact that the motor losses were nearly the 
same in both men. 
Case 11.—Dislocation of right humerus into axilla; reduction 
at third day ; palsy of extensor muscles of hand and fingers; 
nutritive changes; joint lesions. W. C. S., aged fifty-four, 
porter; a thin, ill-nourished man, looking older than 
his admitted age. May 24, 1871, a drunken man seized 
his right arm and shook him so violently as to dislocate 
his right humerus into the axilla, causing pain in the 
shoulder and instant loss of feeling and motion in the hand. 
At the third day, Dr. Knorr, to whose kindness I am 
indebted for the case, reduced the dislocation. The con- 
dition of the arm then began to improve, but at this time 
he first noticed that the hand was swelling. 
July 7.—When examined by me, the whole hand and 
lower side of the forearm were cedematous, and the former 104 
INJURIES OF NERVES. 
also hard and brawnlike, resisting pressure. The fingers 
were in the same state, and the whole hand was dark and 
congested, but not shiny or smooth. The joints from the 
wrist to the finger-ends were sore, swollen, and very stiff. 
The whole palm was the seat of pretty severe burning, 
with no darting or other pain. 
Sensation.—There was partial loss of touch- and pain- 
sense in the median and radial distribution. 
The arms were of the same size. The elbow motions, 
pronation and supination, were perfect, but the latter was 
feeble. Wrist flexion was good, but limited by the joint 
lesion. Extension of the wrist was lost from paralysis. 
Power to flex the fingers was fair, but their movement 
was somewhat impaired, owing to the diseased joints. All 
extension power, and the lateral motions of the fingers, 
were absent, from palsy of the extensors and of the inter- 
osseal groups of muscles. 
Electric condition.—The palsied muscles all responded to 
strong primary induced currents. 
Injury of nerves from fracture of bones. — Contusion or 
laceration of nerves from fracture of bones is fortunately 
rare, and is most commonly encountered in such accidents 
as involve the humerus and the bony parts forming the 
elbow-joint. Similar accidents are met with in the forearm, 
and fractures about the face involve also, though rarely, 
the nerves which pierce its various foramina. In the legs, 
owing to their larger mass of cushioning muscles, direct 
injury from fracture is infrequent, but it is sometimes met 
with in pelvic fracture through the sciatic notch. 
Ferreol-Reuillet,* who has written a very full essay on 
this subject, reports several cases of contusion or lacera- 
tion owing to fracture. In the Edinburgh Med. and Surg. 
Journal,f Granger has three cases of fracture of the inner 
* Etude sur les Paralysies du Membre superieur liees aux Fractures de 
l’Humerus. Paris, 1869. 
f Yol. xiv. p. 196. 1818. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
105 
condyle with paralysis of the ulnar nerve. Coulon relates 
an instance of intra-articular fracture of the external con- 
dyle of the humerus with anterior luxation of the elbow, 
and radial palsy, an accident which I once met with in the 
United States Army Hospital. The history was obscure, 
and the patient having been badly treated, the palsy proved 
very unmanageable under the most industrious and varied 
treatment. Mr. Swan also reports a number of interest- 
ing instances of these injuries, some of them very curious. 
One, a fracture of the glenoid cavity, resulted in violent 
neuralgia of long continuance, but was finally relieved. 
Mr. Earle’s* case of entire brachial palsy from fracture 
of the clavicle was also fortunate in its issue, which is 
not always the case where this accident has been due to 
direct violence. I have now under my care a gentleman 
from Maryland who suffered in this manner, and who 
has been for nearly a year the victim of neuralgia, in the 
radial distribution principally,—the attendant palsy, which 
was at first severe, being now but slight. The pain came 
on at the time he was hurt, and the amount of callus is 
unusually small. 
Perhaps the nerve most frequently injured in the arm 
is the musculo-spiral. In some cases the main trunk is 
hurt, in others one of its two great divisions. I have met 
with one case of this nature resulting in wrist-drop; and 
very lately Mr. Erichsen has reported most valuable his- 
tories of like accidents with all possible care and fullness 
of detail.f 
Injuries to the interosseous nerve in the forearm are 
sometimes encountered, but as a rule the nerve is more 
apt to suffer from secondary changes than from the first 
violence of the fracture. 
* Med.-Chirurg. Trans., vol. vii. 1816. 
f Lancet, July, 1871. 106 
INJURIES OF NERVES. 
A number of sucli cases were seen in tbe United States 
Hospital for Nervous Diseases, all of them from ball wounds. 
Two of these proved altogether hopeless, as must usually 
be the case with nerve wounds the result of bone frac- 
tures from missiles. 
As regards the femur, lesions grave enough to break 
and displace fragments from one end of the bone so as to 
injure a great nerve, are rarely seen except as the result 
of machine or railway injuries. Mr. Swan reports a case 
of double fracture of the neck of the femur,—the patient 
surviving two months. There was intense pain, which 
proved to have been due to direct injury of the sciatic 
nerve by the broken bone.* 
Smithf details a curious case of double fracture of both 
bones of the leg, in which the anterior tibial nerve had 
been torn across, occasioning intense neuralgia and sub- 
sequently demanding amputation. Alquie, quoted by 
Reuillet,J relates a somewhat similar history of injury to 
the same nerve, which I have once seen wounded by a 
ball fracture, where apparently the lesion had been due 
to a fragment of bone driven against the nerve. This case 
occurred in the Filbert Street United States Hospital, 
and was discharged uncured, and, indeed, unrelieved. 
I have not met, either in practice or in my reading, 
with cases of injury to the iiftercostal nerves from frac- 
tured ribs. Yet it seems quite possible that where this 
accident has been due to direct force such a complication 
might well occur. The best collection of cases of fracture 
resulting in nerve wounds is to be met with in an excel- 
lent paper by Mr. Callender.§ 
The sole remaining instance of neural injury of the 
* Swan, op. cit , p. 108. 
f Dublin Journ. Med. Sci., vol. xv. p. 234. 1839. 
X Bull. Gen. de Therap. 1848. 
\ St. Bartholomew’s Hospital Reports, vol. vi., 1870, p. 33 et seq. VARIETIES OE MECHANICAL . INJURIES OE NERVES. 
107 
lower limbs in my own experience, I saw in consultation 
with Dr. W. W. Keen. The patient fell some forty feet, 
breaking the pelvis through the sciatic notch, and appar- 
ently bruising the sciatic nerve at its point of emergence 
from the pelvis. Intense neuralgia followed, with eausal- 
gia in the sciatic distribution, which was promptly relieved 
by a succession of blisters. The patient made, finally, a 
complete recovery. 
In gunshot fractures, as I have before observed, frag- 
ments of broken bones are sometimes driven against dis- 
tant nerves. Perhaps one of the most instructive of such 
histories is that of Seymour,* which I have elsewhere 
related more fully. A ball entered the left neck, below 
the left meatus auditorius, slightly splintered the posterior 
angle of the jaw, and emerged a little above the clavicle 
on the right; besides the left side injuries, the right infe- 
rior branch of the fifth nerve was cut off by a splinter of 
bone, which was torn from the jaw and driven across the 
neck. 
Compression.—Either from external or internal causes, 
the nerves of the human frame are subject to a great 
variety of modes of pressure, yet very little attention has 
been given to the nature of the changes which they bring 
about, and still less to the difference in symptoms which 
arises from the varying rate with which the pressure is 
applied. 
Augustus Waller,fin 1862, and Bastien and Vulpian,f 
in 1855, have done something to complete our knowl- 
edge of the phenomena which attend upon compression. 
In the experiments of these observers, the pressure 
which they made on their own nerves, or those of others, 
* See Chapter VIII. 
f Proc. Koyal Society, 1860-62. 
J Gaz. Medicate, 1855, p. 794. 108 
INJURIES OF NERVES. 
was usually limited to half an hour or an hour. Their 
results, therefore, however valuable, fail to enlighten us 
as to the effects which weeks or months of gradually 
increasing compression may bring about. In fact, rapid 
or slow pressure upon nerves present distinctive differ- 
ences of very striking character, so that while the former 
is apt to occasion most severe and positive suffering, the 
latter may sometimes cause extensive muscular wasting 
without sensory loss of any kind whatsoever. Neverthe- 
less, in a vast number of cases of pressure on nerves, we 
have presented, with some modifications, the sequence of 
symptoms related by Bastien and Vulpian, while it is also 
true, as a clinical fact, that there are many and curious 
variations from this physiological programme. 
These observers divide the phenomena of acute com- 
pression into two periods, the first extending from the 
moment of making compression up to that of ceasing it; 
the second, from this latter date up to the time of the 
return of the normal status. Each period is divisible into 
four stages, more or less distinct from one another. 
First period: stage first is marked by delusive sensory 
impressions, such as formication, prickling, and a sense 
of warmth, which may exist throughout the whole period 
of pressure. There are also said to be false cramps, what- 
ever these may be, while tactility and motility remain 
unaltered. This stage begins with the first moment of 
compression, and lasts from two to ten minutes. 
Stage second is characterized as the intermediary sta- 
dium. It lasts from a few seconds to a quarter of an hour, 
and in it disappear all the symptoms of the former stage, 
to be followed by a seeming return to the normal condi- 
tion and feelings. 
Stage third. Hypersesthesia is here the prevalent char- 
acter, all the forms of sensation becoming exalted, but the 
muscular function still remaining unaltered. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
109 
Stage fourth. Ilypersesthesia passes more deeply into 
the tissues, and the exaggerated sensibilities become in 
turn perverted, and are lost. Before entering upon this 
anaesthetic condition, the tactile sense gives us false im- 
pressions of roughness on the skin, and the sense of pain 
fnrnishes the impression of peripheral burning. The suc- 
cessive, and, so to speak, isolated way in which each mode 
of sensation vanishes, explains how it is that, in this stage, 
at the moment when tactile sensibility is abolished, the 
sensibility to pain may remain unperverted, or exist for a 
time in an extremely exaggerated shape. Nevertheless, 
the deeper tissues continue in a condition of exalted sen- 
sibility. The muscles are now subject to a feeling of 
fatigue and weariness. Yague pains or cramps attack them, 
and the movements become less and less easy. We have, 
at length, muscular palsy, with general local anaesthesia. 
The pressure is now taken oft', and at once the period 
of decline begins. 
This, like that of the augmenting symptoms, has four 
stages: 
Stage ftrst. For a brief period, not over two minutes, 
the muscles remain palsied and the skin insensible, while 
the deeper pains disappear. 
Stage second. Passing backward, as it were, through 
the changes of the first period, there is now slight and 
improving muscular power. The sensibility to touch, 
pain, and tickling returns, and although perverted and 
hypenesthetic, soon becomes nearly normal, the thermal 
sense alone remaining very imperfect. After a time, which 
varies from a few seconds to a minute, the third stage, 
which the authors term intermediate, begins, and is 
marked by normal motility and sensibility, and by con- 
tinued obtuseness to changes of temperature. 
Stage fourth. The patient has sudden sense of cold, 
which is centrifugal in its movement through the part 110 
INJURIES OF NERVES. 
involved, and to this succeeds a local feeling of enormous 
weight, which makes movement difficult. At the same 
time there is general uneasiness, with possibly syncope, 
and the feeling for which there is no scientific term, hut 
which is known popularly as a setting of the teeth on edge, 
and which seems to pass inward towards the centres. 
In the muscular sphere, contractions, and even cramps, 
occur, and the voluntary motions are awkward and diffi- 
cult, while the feeling of formication returns with marked 
distinctness, and the whole limb feels as though it were 
vibrating. Finally, motion becomes regular, the sensory 
perversions cease, and last of all the thermal sense returns, 
the duration of this stage being from some minutes to a 
quarter of an hour.* 
Augustus Wallerf has left on record a careful study of 
the effects of rapid compression of the ulnar, median, and 
musculo-spiral nerves, with excellent observations upon 
the temperature of the parts. The French experiments 
are detailed with more method, but in essentials the two 
sets of observations sufficiently agree. While, however, 
Bastien and Vulpian describe as constant the curious re- 
turn of normal feelings a little while after pressure has 
begun, all sense of warmth, formication, and prickling 
being lost for the time, Waller speaks of the same phe- 
nomena as occasional in the early stages of compression. 
All of these observers agree that this affection of nerves 
may produce vertigo and nausea, but only Waller has 
pointed out that when a single nerve has been pressed 
upon, the final loss of motility is not confined to its mus- 
cles alone, and this is in strict accordance with my own 
•clinical experience. 
It appears, therefore, that when a nerve of sensation 
* Memoire sur les Effets de la Compression des Nerfs. J. B. Bastien et 
A. Yulpian. Gaz. Med. de Paris, 1855, p. 794. 
f Proc. London Royal Society, May 15, 1862, p. 89 et seq. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
and motion has been rapidly compressed, there are, at 
tirst, false sensory impressions, which come and go with 
normal intervals; then hyperEesthetic conditions of touch, 
pain, and temperature follow, to be succeeded by per- 
versions of sense with spasmodic muscular movements. 
After these come total anaesthesia and absolute palsy. 
When the pressure has been removed, rapid recovery of 
sense and motion ensue, unless the pressure has been 
severe and long continued. In one instance, where Waller 
compressed his left radial nerve forty-live minutes, both 
sense and motion suffered for eleven days before the health 
of the part was re-established; and when repeating on 
myself his experiments, I found that many days were 
always needed to restore completely the normal feelings. 
Experiments on the effects of pressure.—It has seemed to 
me that there was still some room for inquiry as to the 
mechanical influence of pressure. A nerve trunk is made 
up of a multitude of tubes, the contents of which are so 
nearly fluid as probably to be capable of more or less move- 
ment to and fro. When to such a bundle we apply a tight 
ligature, no matter how soon it be relaxed, we annihilate 
at once all power of the nerve to transmit impressions 
past the injured zone. If, however, in place of this, we 
make gradual and equal pressure, we may so affect the 
nerve as for a time to destroy its power to carry impres- 
sions. Now this is exactly what occurs in many cases of 
compression,—the nerve is for a time incapacitated, but 
soon regains its normal abilities. It seemed to me that 
the reason for such loss and such return must be purely 
mechanical, and that perhaps even the amount of pressure 
needed to arrest the passage of nerve force might be 
capable of mensuration. 
The following experiments, which were made at va- 
rious times with this intent, will not, I hope, be without 
interest: 112 
INJURIES OF NERVES. 
A tube of glass, enlarged a little at the extremities, one- 
tenth of an inch in diameter and twenty-one inches long, 
was htted at one end with a thin caoutchouc cover. 
Having laid hare the sciatic nerve of a rabbit, and slipped 
under it a thin cork, I allowed the bladder closing the 
tube to press lightly on the nerve trunk, the lateral ex- 
pansion of the bag being limited by a ring of cork, nicked 
below so as to rest on the flat cork and yet to allow of the 
passage of the nerve. Two inches of mercury were then 
poured into the tube, so tilted as not to permit of the 
nerve being hurt by the fall of this heavy metal. The 
tube was next raised to the perpendicular position. The 
first effect was to cause slight twitching and some expres- 
sion of pain. To save pain and to leave only the better 
test of muscular movement, I divided the nerve an inch 
from the tube on the central side. The quantity of quick- 
silver was now slowly increased. Each increment was apt 
to produce new twitches, as was also any sudden movement 
of the tube; but constant pressure, like an uninterrupted 
galvanic current, gave, after the first movements, no 
further result. As each half-inch or more of mercury was 
added to the column, I tested the nerve from time to time 
on the central side with a current from a small single 
Smee cell. The communication seemed to be unbroken, 
and muscular movements could be thus excited until I 
had put on the nerve a pressure of twenty inches of mer- 
cury. Ten or twelve seconds of this pressure gradually 
lessened, and at last abolished, the power of the nerve to 
carry to the muscles the impression made by the gal- 
vanism. 
The tube was then lifted carefully, when to my surprise 
(and great interest) I found a gradual return of this power 
of transmission, although ten or fifteen seconds elapsed 
before the first visible manifestation occurred. 
These experiments, made chiefly on rabbits, and varied VARIETIES OF MECHANICAL INJURIES OF NERVES. 
113 
somewhat, so as to place the nerve between two caout- 
chouc bags of mercury, gave, on the whole, the same 
general result. For the sciatic nerve a few seconds—ten 
to thirty—of the pressure of a mercury column, eighteen 
to twenty inches high, broke the communications between 
two portions of a nerve. Relieved from pressure, the 
nerve speedily recovered. 
It seems impossible to look upon this as other than a 
mere mechanical disturbance of the tubal contents, and a 
like mechanical restoration of their needed conditions for 
activity. 
It is needless to speculate here upon the very suggest- 
ive character of these observations in a physiological point 
of view. Pathologically considered, they are not less 
interesting. 
Remembering the delicate nature of the neural tissues, it 
seems inconceivable that twenty inches of mercury should 
not destroy them utterly. Moreover, what is the change 
which really takes place, and does it seem possible that 
the axis cylinders could be so broken as to refuse their 
office, and yet so reunite in a few seconds as to be tit again 
for functional duty? 
From another standpoint the experiment seems to widen 
the breach between nerve force and electricity, there being, 
as regards the latter, no analogy to this observation. 
I have made careful examinations of nerves which have 
been thus treated by compression. In all of them were 
noted some evidences of congestion, but the chief lesion 
lay in a very extensive disturbance of the contents of the 
nerve tubes. In some of them I could find scarcely an 
unaltered nerve tube, the neural tissues looking much as 
they do seven or eight days after section. Yet through 
the tubes so disturbed the nerve force still has power to 
travel. 
These observations appear to me full of importance 114 
INJURIES OF NERVES. 
when we come to apply them to explain actual injuries, 
and with their aid to recall the need for certain me- 
chanical conditions in order to the integrity of neural 
function. 
Various forms of pressure.—It may, perhaps, seem need- 
less to enumerate at length the various means by which 
pressure is exercised upon nerves; but it does often hap- 
pen that this cause of paralysis escapes notice, so that 
again and again, both in military and civil practice, I 
have met with cases in which physicians had failed to 
comprehend the true agency at work in producing the 
symptoms. 
The causes productive of pressure upon nerves may be 
conveniently divided into those which act from within the 
body, and physical agents which affect it from the exte- 
rior. As a rule, the former act slowly, the latter more 
rapidly, so that the results vary somewhat, as I have had 
occasion to point out when discussing the physiological 
pathology of nerve lesions. 
Inflammatory pressure.—It is extremely probable, as I 
have already stated, that inflammation occasions com- 
pression of nerve branches, and that the pain which ac- 
companies this condition is largely due to this physical 
influence. It is also certain that the nerves of inflamed 
tissues are more sensitive than others to disturbing agen- 
cies, so that any artificial or other increase of the normal 
pressure still further disturbs them. Compression by in- 
flammation is most troublesome at the points where nerves 
pass through bony foramina, and this is best illustrated 
where, as in the sciatic, the inflamed nerve is so placed as 
to be hurt whenever the motions of the limb alter its 
relation to the opening through which it escapes. 
I am at present treating a man from Tennessee, who 
received in a scuffle a kick which injured the sciatic nerve 
at its point of emergence. The blow caused intense pain, VARIETIES OF MECHANICAL INJURIES OF NERVES. 
115 
and in a few hours local tenderness was followed by tin- 
gling and numbness in its track and ultimate distribution. 
These symptoms slowly increased for several weeks, 
despite local bleeding and blisters. Three months after 
the injury there was still tenderness on pressure in the 
path of the nerve, some loss of power, and intense pain 
whenever the leg was allowed to move backward beyond 
a certain limit, which the patient has learned to recognize 
accurately. Rotation of the leg inward also produced 
this result, which is due I suppose to the nerve being at 
these times in some way pressed upon at its outlet. 
Pressure by cicatrices.—Cicatrix pressure from the heal- 
ing of wounds must be unusual, as we saw it rarely 
in our hospital experience. Two cases which I recall 
were deep wounds of the thigh, and in both passive mo- 
tion, and, finally, enforced activity, gave relief, which 
had been denied so long as we kept the patients at rest, 
a useful lesson as to the need for experimental treatment 
in individual cases. In the second of these men, the 
cicatrix lay across and very near to the sciatic nerve, so 
that whenever the leg was straightened, the man suddenly 
lost power and suffered pain. 
In other instances where wounds had been allowed to 
heal with the limb bent, or otherwise misplaced, the 
resultant neuralgia seemed to be due to compression, and 
was relieved rapidly enough by restoring the normal 
movements and by the douche and frictions. Superficial 
shell wounds also were found in rare cases to occasion 
pain by cicatrix compression of sensitive cutaneous nerves, 
but none of these proved obstinate under proper treat- 
ment. 
Considering broadly all cicatrices and the extent to 
which they contract, it seems singular that so few are 
sensitive or give evidence of compression on the part of 
the included nerves; so that I am led to suspect the ex- 116 
• INJURIES OF NERVES. 
istence, in the few painful cases, of some coefficient fac- 
tor besides the physical condition to which I have been 
alluding. Painful scars have been again and again ex- 
tirpated, but I have been unable to find any microscopic 
examination of the state of their contained nerve fibres. 
The nearest approach to a satisfactory insight in this 
direction is to be had from a study of the terrible Spe- 
dalksed or Tubercular Leprosy of Norway. 
Danielson and Boeck* have shown that in the anaes- 
thetic form of this disease the nerves undergo certain 
changes which are finally propagated from periphery to 
centre. The earlier symptoms are neuralgia, with tingling, 
and liypersesthesia, which become intense, and are fol- 
lowed by anaesthesia and loss of motion, much as happens 
in the gradual compression of nerves. The earlier of 
these symptoms seem to be related to simple congestion 
of the neurilemma; the succeeding and latest phenomena 
are due to a hyperplasia of the connective tissues within 
and without the nerve sheath, which occasions compres- 
sion of the nerve fibres, and ultimate extinction of their 
functional life. 
Perhaps some such alteration may occur in the nerves 
of certain painful scars, but it seems at all events quite 
certain than in others which have undergone like con- 
traction no nerve injury exists, so that we must look 
further than the mere fact of cicatricial contractions, and 
concede the existence of other and unstudied pathological 
conditions. 
Pressure from callus.—Pressure upon nerves by the ex- 
cessive growth of callus used to be thought a common oc- 
currence; but although nerves are sometimes imprisoned 
in forming callus, there does not seem to be in it any 
* Eecueil d’Observations sur les Maladies de la Peau. W. Boeck et C. 
Danielson. Christiania, 1860. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
117 
liability to contract like cicatrices elsewhere, and hence 
the nerve, however closely confined, may escape altogether 
undue pressure. 
Among the many animals examined by Ollier after he 
had caused fractures of bones, in one only did he find 
a nerve caught in the callus, while every effort to place 
nerves so as to engage them in the callus failed altogether. 
It seems, then, from experimental data, “that compres- 
sion of healthy nerves in callus is not habitual” (Reuillet); 
whether it ever happens, this author considers doubtful, 
but he is inclined to believe that a nerve injured in any 
way, and slowly enlarging from neuritis while incarcerated 
in the hardening callus, may suffer severely. 
This is a state of things not unlikely to occur; but 
there are no recorded cases which I have been able to find 
justifying so likely an hypothesis except that reported 
by Ollier.* 
Case 12.— Aug. Lombard, aged twenty-two years, suf- 
fered a fracture of the humerus at the upper line of the 
lower two-fiftlis of the bone. The fracture was placed in 
a starch bandage for forty days, during the earlier of 
which the man had lively lancinating pains at the point 
of fracture. 
On removal of the apparatus, the extensors were found 
to be paralyzed. Four months later, M. Ollier, after 
careful examination, concluded that the radial nerve was 
suffering primarily from compression by bony fragments, 
and secondarily by callus. All other means failing, Ollier 
cut down in the line of the nerve, and found it, as he 
says, “swollen like a ganglion, and.strangled by a piece 
of bone obliquely placed and appearing to belong to the 
lower fragment. This point was, in fact, continuous at its 
base with the lower end of the bone, which was itself 
Eeuillet, op cit., p. 49. 118 
INJURIES OF NERVES. 
confounded, so to speak, in a mass of peripheral callus.” 
“At this level the nerve was compressed as by a ligature, 
and measured three millimetres in diameter, while above, 
the swollen trunk attained one centimetre in width, and 
below this point was only slightly enlarged. A little 
lower it was of normal size, although still lying for 
fifteen to twenty millimetres of its length in the heart of 
the callus.” The osseous point was removed, and the nerve 
left resting in a gutter, broadly hollowed for it in the 
bone, from which the periosteum was removed. Nearly 
perfect recovery took place. 
Besides this interesting history of bold and sagacious 
surgical interference, there are but few instances of nerve 
injury from the pressure of callus. An instructive case, 
which occurred in the practice of Mr. Hilton, is related 
by Sir James Paget,* and Swan has reported an instance 
somewhat similar in character. In the former case, a 
man who had a fracture of the lower end of the radius 
had his median nerve compressed by a large mass of 
callus. His thumb and first and second fingers ulcerated, 
and the ulcers resisted all treatment until the wrist was 
kept bent in such a way as to relieve the nerve from press- 
ure. The ulcers returned whenever the hand was allowed 
to assume its former position. 
Gurlt has also related an undoubted instance of callus 
pressure; but how rare these accidents are may be gath- 
ered from the fact that neither Hamilton nor Malgaigue 
relates a single example. I have seen three cases, at least, 
of extensive callus following gunshot wounds of bone, in 
which there must have been imprisonment of nerve trunks. 
In one only, a wound of the forearm, was there any 
evidence of pressure, and in this case the symptoms were 
most probably due to injury produced at the time of the 
wounding. 
* Surgical Pathology, vol. i. p. 43. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
119 
Verneuil communicated to Tillaux a case of formation 
of callus, which is probably unique as yet in medicine. 
A gunshot wound broke the elbow, and after resection, 
amputation became necessary at the close of a month. 
On examination, the radial nerve, a little above the bend 
of the elbow, was found swollen and inflamed, and on one 
side of the enlargement, and penetrating it, was seen an 
irregular bony mass of the size of a bean, and plainly of 
recent formation, as the color, feeble consistence, and the 
form of its osteoplasts attested. As this was not a piece 
of old bone, it was probably due, as M. Verneuil believed, 
to a morsel of accidentally transplanted periosteum, which 
bad given rise to a certain amount of ossification at a 
point quite remote from the callus. 
Pressure by tumors.—The gradual growth of pathologi- 
cal new formations in almost any region of the body is 
a common cause of pressure upon nerves. Here, as in 
other examples of compression, it is important to consider 
two points,—the rate of growth in the compressing mass, 
and the anatomical relations of the nerves affected. In 
most cases of nerves of mixed function, we have the usual 
sequence pointed out by Bastien and Yulpian. First 
prickling, tingling, and sense of heat, then exaltation of 
sensory function and even hypersesthesia, with finally loss 
of sensibility and motion. The speed with which these 
follow one another is governed by the rapidity of growth 
of the compressing mass, and the ease with which the 
nerves influenced are capable of suffering from the physi- 
cal effect. This will depend in a great measure upon how 
firmly they are tied down. Tumors occurring in relation 
to the sciatic, for example, at the middle of the thigh, 
easily carry it with them unharmed for some time, and 
until the growth has become very large. But a tumor 
near to the outlet of this nerve, or a subperiosteal growth 
within the pelvis and beneath the points of emergence of 120 
INJURIES OF NERVES. 
the lumbar nerves, is early and disastrously evident in 
the way of pain and other disturbing phenomena. 
These remarks apply generally to this subject, and to 
give examples throughout the body would be only to an- 
ticipate what I may have to say as to alterations of par- 
ticular nerves. As a rule, fibroid and other formations 
of this nature, as well as aneurisms and syphilitic growths, 
give examples in their relations to nerves of simple press- 
ure or elongation, but cancers may very early affect the 
nerve tissue, and occasion results which are due to other 
than merely physical causes. 
I have seen instances of this in cases of carcinoma 
involving the lumbar plexus, in masses of a size too small 
to account by pressure alone for the agonizing pain in the 
lower limbs. 
In two such cases I found the nerve trunks enlarged 
and reddened; so that here, as elsewhere, inflammatory 
conditions determine an early manifestation of pain in 
stretched or compressed nerves.* 
The following very interesting history is a good ex- 
ample of the difficulties which sometimes surround the 
earlier stages of these cases : 
Case 13.—In April, 1871, J. H., a porter, aged sixty-six 
years, presented himself at my clinic for nervous diseases. 
He was thin, sallow, and feeble. Three years before he had 
strained his back while carrying a trunk. The pain in 
the coccygeal region, with a sense of something having 
given away, was intense at the time, but slowly lessened, 
never, however, being wholly absent. Two years ago he 
began to have difficulty in urinating, with numbness in 
the left leg, and pain in the track of the sciatic nerve. At 
times the leg was weak; usually it was as strong as the 
other limb. When the pain in the leg was most severe, 
* Romberg, vol. i. p. 10, Sydenham Society’s Translation. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
121 
that in the coccyx also increased. The sense of touch was 
nowhere impaired, but the whole leg, and the anterior 
crural region, as well as the penis, always felt unnatural. 
The spine and coccyx exhibited no tenderness, hut the 
sciatic nerve, at its exit and in the thigh, as well as the 
whole left buttock, were sensitive to pressure. Presuming 
that we had to do with a case of slight neuritis, and per- 
haps of inflammation of the lower end of the cord, I 
ordered ergot, tonics, and ice to the nerve track. 
On his return, some weeks later, my assistant, Dr. Whar- 
ton Sinkler, noticed that the buttock was enlarged. On 
carefully re-examining the part, we then observed that it 
was also too firm, and that the surface was covered with 
dilated vessels, its temperature being at least a degree 
above that of the other side. To remove my doubts, I 
plunged a hollow needle into the mass, and after rotating 
it, so as with its sharp, penlike edges to cut loose small 
pieces of the tissue, I applied a syringe, and by its aid 
sucked up a little blood and several of the loosened frag- 
ments.* There was no pus, but the shreds, when exam- 
ined, proved almost certainly to be cancerous. 
As regards their early influence upon the nerves they 
stretch or compress, aneurismal growths probably act 
sooner than innocent fibro-plastic masses, because of their 
continual pulsating movement. In the abdomen, aortic 
aneurism is apt to occasion pain, which is one of the 
earlier signs of disease, and sometimes antedates all other 
forms of deeper constitutional disturbance. 
In the chest or neck, the nerve affections due to tho- 
racic aneurisms are seen in the form of hoarseness or 
aphonia, from injury to the vagus or recurrent laryngeal 
* This method is far more sure to bring away the needed portions of 
tissue than Duchenne’s trocar, which often fails, and has the disad*- 
vantage of not securing any fluid which may he present. 122 
INJURIES OF NERVES. 
nerves, or in affections of the pupil from lesions of the 
sympathetic nerve,—effects which may also arise from 
glandular and other enlargements. 
As interesting illustrations of some of the conditions 
which have influence in cases of pressure on nerves by 
tumors, as well as of skillful surgical interference, the two 
following cases may answer. 
Dr. D. Hayes Agnew* presented to the Pathological 
Society of Philadelphia a bursal tumor, about an inch in 
diameter. It had occupied a place at the bend of the 
elbow, on the inner side of the tendon of the biceps, 
causing pain and loss of motion in the flexors of the 
thumb and Angers, and the extensors in general. It was 
so bound down by the deep fascia as to project but slightly, 
and to greatly exaggerate the pressure it was making upon 
the nerves. After cutting through the bicipital aponeu- 
rosis, the growth was found to be invested on the surface 
by the flattened median nerve. 
On dissecting this away, pushing it aside, and turning 
out the mass, a like connection was discovered beneath it 
with the posterior interosseous trunk. It was thus endan- 
gering both nerves at once; but, notwithstanding this 
curious complication, the recovery which followed its 
removal was in all respects satisfactory. 
On the same evening, Dr. Packardf exhibited to the 
same society, a tumor as large as a lemon, which grew 
just under the lower edge of the gluteus maximus. Its 
position caused incessant pressure upon the sciatic nerve, 
and made motion painful, and rest on the back or left side 
impossible. 
For eight months the patient had been unable to remain 
in bed, and found only temporary ease in incessant 
changes of posture. Removal of the mass was readily 
* Proc. Path. Soc. of Phila., Oct. 1863. 
f Ibid. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
accomplished, and was speedily followed by relief from 
the pain, numbness, and swelling. 
Compression of nerves during delivery.—Cases of paralysis 
of one or both lower limbs are somewhat rare sequelae of 
confinements. They may be traced to a variety of causes, 
among which are undoubtedly the pressure of the fcetal 
head or of the forceps. 
Although frequently denied as a cause of palsy, pressure 
is now, and has been for a long time, admitted by all the 
prominent writers upon the complications and results of 
labor. The subject is admirably treated in all its relations 
by Bianehi,* to whose excellent pamphlet I am largely 
indebted. 
This form of accident in some cases immediately suc- 
ceeds the passage of the fcetal head; in others it is delayed 
several days. In the latter, however, at least in the in- 
stances I myself have seen, there were numbness and 
hypersesthesia, which deepened by degrees, and finally 
ended in partial palsy, a sequence due sometimes to the 
pressure having occasioned a gradually-increasing neu- 
ritis, just as is seen in the contusion of nerves elsewhere. 
In many labors, as every accoucheur is aware, cramp- 
pain from pressure is met with. The nerves which may 
be thus, or more gravely, affected, are the crural, obtu- 
rator, and sciatic. The first named is apt to suffer during 
the earlier stages of labor, and, as Burnsf has pointed out, 
to occasion pain in the front of the thigh. 
Severer injury to this trunk is unlikely, owing to its 
protection by the psoas and iliacus muscles. The obtu- 
rator nerve is also liable to pressure, and to give rise to 
similar but passing pains. Within the pelvic excavation 
* Des Paralysies traumatiques des Membres Inferieurs chez des Nou- 
velles-Accouchees. These de Paris, 1867. 
f Burns’s Midwifery, p. 14. 124 
INJURIES OF NERVES. 
the sacral plexus and its greater sciatic branch are the 
nerve tissues most liable to serious injury, and it is usu- 
ally to compression of this latter nerve that we must look 
for an explanation of such cases of infra-pelvic palsy as 
follow labor, and are due to this physical cause. 
Bianchi asks,: very shrewdly, if it be not also possible 
that compression of the sympathetic filaments may have 
some influence in predisposing the uterus to the conges- 
tions and inflammations which occasionally follow deliv- 
ery. Considering the well-known effect, in this direction, 
of sections of vaso-motor nerves in the abdomen and 
thorax, I myself should be disposed to attribute far more 
to this possible cause of disease than has hitherto been 
done. 
While it is clear from the cramps so common in labor 
that the nerves are frequently compressed, it is also plain 
that this compression is rarely adequate to a graver result, 
and the chief reason for this is to be found in the ana- 
tomical arrangements of the pelvis. The sciatic nerves, 
resting as it were in deep gutters, the projection of the 
sacro-vertebral spine* tends to ward off’ from them the 
pressure of the foetal head, “while the sacral nerves resting 
against the back wall of the excavation are in some degree 
saved, owing to the fact that the inclination of the planes 
and axes of the bassin, direct against the anterior walls 
and symphysis pubis the principal effects of the greatest 
pressure of the foetal head.”f 
I may add to these remarks that the pelvic nerves have 
remarkably thick sheaths; that, like other nerves, they 
endure a good deal of squeezing and pressure without 
lasting injury, and finally, that, as Bianchi has shown, it 
is usually the forceps, rather than the head alone, which 
is at fault. Indeed, he has been unable to discover any 
* Bianchl, p. 40. 
f Ibid VARIETIES OF MECHANICAL INJURIES OF NERVES. 
125 
instance where palsy from pressure followed a labor end- 
ing without the forceps, and he seems therefore inclined 
to conclude that it is to the lateral movefnents of this 
instrument, combined with violent traction, that we must 
attribute the nerve lesion. In this view he seems to be 
supported by the five histories he reports, all of which were 
those of forceps cases. On the other hand, the cases seen 
by mj? friend I)r. Keating were not all forceps cases. And 
my own example!, two in number, were in fact merely 
prolonged labors, but in other respects natural, so that, 
as Jaccoud* believes and Burns taught, this accident may 
follow even a very regular and natural delivery. Never- 
theless, histories of post-partum palsy from pressure are 
so rare that the cases I append may not lack interest. 
Case 14.—C. L., a sturdy Irishwoman, confined with her 
second child, suffered excruciating cramp in the left leg 
during a labor which lasted nearly two days, but except 
as to its duration was normal. The pain of the cramp was 
so intense as twice to cause the patient to faint. The day 
after her delivery she complained of pain on the outside 
of the leg and foot, and of prickling and numbness. 
When well enough to sit up, it was found that she had 
great weakness of the left leg, which increased, until 
within one month its use was nearly lost. A little later she 
began to amend, and under various treatment recovered 
entirely within a year. 
Case 15.—M. B., aged twenty-six. The second exam- 
ple occurred lately in a young and vigorous woman, 
wrhose second labor, prolonged by the size of the foetal 
head, occasioned great pain and numbness in the limbs. 
At the twelfth day she was still suffering from slight 
anaesthesia of the right leg, and from numbness and loss 
of power in both. Her recovery, under the use of vig- 
* Sur les Paraplegics, p. 290. 126 
INJURIES OF NERVES. 
orous shampooing and small doses of nux vomica, was 
very tardy; nor was she able to walk before the fifth week. 
There was no sciatic tenderness at any time. 
I may add with Jaccoud, that this peculiar pathogenesis 
of palsy of the legs by pressure is not found in deliveries 
only, since any intra-pelvic tumor, sufficiently hard, may 
give occasion to it. I recall a case of enormous post- 
uterine hsematocele, in which there was great pain in the 
track of the sciatic nerve, and Bernuilly has related to 
Jaccoud the interesting history of a post-uterine tumor 
causing paraplegia, which was relieved when the mass 
suppurated and broke into the rectum. 
Pressure from fecal accumulations.—It is perhaps within 
every one’s experience that the violent effort to expel a 
mass of hardened faeces is competent to cause pain down 
the back of the thigh, and serious compression of the 
nerves of the lumbar plexus is said to have been caused 
by accumulations in the bowels,—a circumstance which 
I have never met with even in the most extreme instances 
of this disorder. 
Probably most of the cases of pain from inactive intes- 
tines are due rather to reflected irritations than to more 
direct physical causes. Portal* relates, however, the 
strange case of a certain Madame de Roye, who, being 
deformed by a spinal curvature, suffered intensely from 
pain in the left great-toe. Injections increased it, but a 
full stool gave relief. Upon her death, from malignant 
fever, it w&s found that, owing to the spinal curve, the 
lowest of the false ribs were so pressed in upon the sig- 
moid flexure of the colon as to cause an accumulation 
of excrement sufficient to compress the nerves of the 
lumbar plexus, and thus occasion an affection of the 
crural nerve, and, consequently, of its saphena branch. 
* Cours d’Anatomie Medicate, t. iv. p. 276.' VARIETIES OF MECHANICAL INJURIES OF NERVES. 
127 
Muscular pressure from spasm.—Pressure by muscles in 
a state of chronic spasm might be said to belong to the 
same category of doubtful causes, were it not for Rom- 
berg’s statement that he had occasionally seen enduring 
spasm of the scaleni cause compression of the brachial 
plexus, with resultant numbness, anaesthesia, and oedema 
from venous constriction. 
Compression of the facial (seventh) nerve by the forceps.—This 
accident, although long known to accoucheurs, seems to 
have received its first correct physical explanation from 
Dubois,* who pointed out the mode in which the nerve 
is affected, and showed that the resultant palsy cannot be 
due, as was supposed, to cerebral pressure. 
The thesis of M. Landouzy appears to have been the 
first published collection of cases. 
In certain labors, the blade of the forceps makes press- 
ure either upon the diverging branches of the portio 
dura or upon the main trunk of the seventh, just in 
front of its outlet from the temporal bone,—an accident 
rendered possible in the infant by the slight development 
of the mastoid process and the comparative softness of 
the parts connected with the auditory meatus and jaws. 
When the force is exerted unequally on the dividing fila- 
ments of the nerve, the result will be seen in an incom- 
plete palsy of some parts of the face, and a more perfect 
loss of motion in others.f 
The features are found drawn to the sound side, the 
tongue and palate being unaffected, which has at least 
been the case in Landouzy’s cases and in those which I 
have encountered.| These circumstances usually suffice 
* Landouzy, These, Essai sur l’Hemiplegie faciale chez les Enfants nou- 
veau-nes. Paris, 1839. 
f Op. cit. 
| I shall elsewhere discuss the views of Romberg, Todd, and Saunders 
as to the value of palatal palsy in deciding the seat of the paralyzing 128 
INJURIES OP NERVES. 
to determine that the paralyzing cause has been external 
to the track of the nerve in the temporal bone. 
In the three cases which I have seen, the paralysis was 
very marked, the ala ceasing to move and the eye remain- 
ing open. In two there was difficulty of nursing, hut 
little or none in the third, owing to the large nipples of 
the mother. All of them recovered readily within a 
month and without treatment. I have also seen a patient, 
sent to me from Delaware, the child of a physician, in 
whom there was left facial palsy following a failure to 
terminate a long labor by the forceps. The birth occurred 
naturally several hours afterwards. The palsy existed 
from birth, and at the sixth week, when seen by me, was 
complete. I decided against the instrument as a cause, 
since there was no mark of violence, and because there was 
not only a hanging down of the palate on the affected right 
side, but also of the posterior palatine arch, with oedema 
of these parts, and because of a slight dryness and loss 
of epithelia on the tongue limited to the diseased side. 
The child died soon after of convulsions, with discharge 
of offensive and bloody matter from the left ear. 
As regards the marks made by the forceps, in all of my 
cases there was some indentation, but not always over the 
line of the nerves. It is well to remember, as Landouzy 
has pointed out, that in some instances there is no exter- 
nal trace of violent compression by the forceps blade, so 
that we need not expect in every case to meet with this 
diagnostic aid. Fortunately we rarely need such assist- 
ance, the diagnosis being easy except in rare examples, 
like that of the last case cited. 
Paralysis from local'pressure, on nerves owing to malposition 
during sleep.—Every one has awakened occasionally out of 
cause ; but it seems to me quite certain that in these brief palsys by the 
forceps no loss of palate power is visible. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
129 
deep sleep to find that he has been lying upon his arm, or 
that it has been resting under his head, or in some awk- 
ward posture, owing to which the limb feels numb and 
dead, or may even be insensible to touch. The lapse of 
a few moments usually restores it to full feeling, after a 
short interval of unpleasant prickling and formication. 
There is probably here both nerve pressure and interrupted 
circulation. In rarer instances, permanent palsy has fol- 
lowed the malposition, and this is most apt to occur in the 
deep sleep of debauch. 
Althaus* gives a case of this accident occurring to a 
lady during confinement, and while under the influence 
of chloroform. Her head rested so long on the left arm 
as to cause, by pressure on the brachial nerves, paralysis 
of certain muscles, with anaesthesia. It is interesting to 
note that there was also inflammation of the wrist-joint, 
such as often follows wounds of nerves. 
Usually the arm is the limb involved, but there are 
said to have been examples of facial palsy caused by 
pressure of the hand on the face in deep sleep. I have 
met with no instances of this, either in the books or in 
practice. 
Many examples of partial palsies of the upper extremi- 
ties from pressure during sleep have come under my 
notice. At first, both sensation and motion sutler, but the 
motor palsy usually continues longer, and is more severe. 
The most troublesome cases are those which arise from a 
person having slept with one arm resting on the edge of 
a settee. Two such cases appeared at my clinic recently. 
In both there was hardly any sensory loss, but in both 
there were exactly the same muscular troubles. The 
flexors were perfect, but there was complete palsy of the 
extensors of the wrist, of the first phalanges of the fingers 
* Med. Electr., 2d ed. London, p. 489. 130 
INJURIES OF NERVES. 
and those of the thumb, occasioned in both instances by 
pressure on the musculo-spiral nerve. 
The most remarkable case within my knowledge was 
that of a laborer, who fell asleep in the street on a door- 
step, after drinking heavily. There wrere marks of bruises 
on the back or outside of both arms, as if he had slept 
with the two limbs crossed under and behind his head. 
In fact, he was found by the police resting with one 
arm on the edge of the iron foot-scraper and the other on 
that of the step. lie was so nearly poisoned by the alco- 
hol taken as barely to escape death. On the second day 
he was found to have wrist-drop in both hands. 
A few weeks after, he came under my care, having been 
treated meanwhile for lead palsy, of which he had, how- 
ever, no evidence, save the extensor palsy. lie recovered 
after very prolonged treatment by faradisation. 
M. Bachon reports two cases of palsy of the radial caused 
by pressure during sleep, or in drunkenness. In both the 
arm rested on the back of a chair and the head on the 
arm. Mr. Walter G-. Smith* has published a case of wrist- 
drop and anaesthesia from sleeping on the arm, the man 
being drunk at the time. In his second history a like re- 
sult followed a healthy sleep, with the hand resting on 
the arm. His third case seems to have been due to long 
pressure of the elbow on the nerves of the opposite palm, 
and affected the median nerve chiefly. 
Some persons seem to suffer more, and more readily, 
than others from light pressure on nerves or malposition. 
This is the case, I believe, with anaemic people and those 
in feeble health from any cause, but especially is it notably 
so in such as are in the first stages of spinal palsies or 
locomotor ataxia. 
Some of the remaining external causes of paralysis of 
* The Dublin Quarterly Journal, Aug. 1870, p. 21. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
nerves by pressure are both curious and interesting, 
although but little has been said of them by medical 
writers. 
In most of the severe cases the pressure has been long 
continued, but sometimes we are struck by the shortness 
of the time required to produce prolonged loss of power 
under certain forms of compression, and with the sudden- 
ness of the resultant palsy. Thus, it is not very rare to 
meet with such results from a child’s carrying a package 
by means of a string looped over a linger, or from the 
pressure of a heavy basket on the arm. I have to thank 
my friend Dr. John H. Brinton, late surgeon U. S. Volun- 
teers, for calling to my notice two causes of pressure 
which are very curious, but the latter, at least, I trust 
very rare. 
During prolonged cavalry marches, the pressure of the 
snaffle-rein upon the radial side of the third linger causes 
in some men weakness of this member, distinct enough 
in rare cases to constitute a palsy, which is apt to invade, 
after a time, terminal branches of the ulnar nerve. 
Dr. Brinton* has also met with two instances of local 
palsy which proved very tedious, and were brought about 
by the use of a form of restraint used by the police of 
Philadelphia, and perhaps elsewhere. It consists of a 
cord tied at the ends to two small handles. This cord is 
passed around the arm of a prisoner, and is sometimes 
twisted. The two handles are held in the grasp of the 
officer, who may make the pressure as light or as severe 
as may suit his own views. It is easy to understand how 
mischief may result from the cruel use of this formidable 
means of restraint. 
Still more curious is the pressure-palsy to which the 
* U. S. San. Com Med. Reports. Diseases of Nerves resulting from 
Injury. S. Weir Mitchell, M.D., p. 419. 132 
INJURIES OF NERVES. 
water-carriers of the town of Rennes are liable. An ac- 
count of this singular malady is given by M. Bachon.* 
The water-carriers use a huge iron vessel, holding about 
eighteen quarts of water, and furnished with a single 
handle on the side. The belly of this great vase rests on 
the antero-lateral part of the thorax. The arm thrust 
through the handle, which is turned outward, embraces 
the circumference of the jar, which it presses against the 
side. At the same time the humerus is thrown outward 
and upward, so as to give the handle a solid support. 
This enormous load, which is at least seventy-six pounds, 
exerts by the agency of the handle a strong pressure on 
the external and posterior region of the arm, crossing 
obliquely the direction of the radial nerve. Paralysis of 
the extensors of the wrist and hand is a common con- 
sequence, and in some instances this is complicated by 
neuritis, of which the reporter gives a clear and interesting 
account. 
Crutch palsy.—A common cause of paralysis from press- 
ure in army practice, but one very rare in civil life, was 
known to our hospital staff as “ crutch palsy.” Early in 
the war a great number of instances of this malady were 
sent to our wards, and some occurred while patients were 
under our own care. Such were usually emaciated men, 
who, being of large stature, and therefore of great weight, 
bore heavily upon the cross-piece of the crutch, which 
was commonly of wood, and not cushioned. I do not recol- 
lect seeing this malady in any person whose axilla was 
well defended by adipose tissue, and bj? the firmness and 
tone of the muscular folds which bound it before and be- 
hind. Neither was it frequent after the wounded began 
to be supplied with a proper form of crutch. The trouble 
* Eec. de Mem. de Med., de Chir. et de Pharm. militaires, t. ii. (3 serie) 
quatrieme Fascicule, No. 52, Avril, 1864. VARIETIES OF MECHANICAL INJURIES OF NERVES. 
133 
was met with, of course, in men who had to bear hard on 
the crutch because of a wounded or lost leg. The paralysis 
begins with a tingling and numbness in the little finger of 
one hand, ordinarily the right, with sometimes a loss of 
feeling in the ulnar distribution. Then the hand grows 
feeble, or this symptom comes on, though rarely, without 
previous or accompanying sensory phenomena; but at 
last the patient can no longer grasp his crutch, so that in- 
evitably the disease brings its own remedy of entire rest, 
although it does sometimes continue to increase for a time 
after the crutch has been abandoned. I have seen no case 
which failed to get well, though in certain instances of 
pressure from other causes the palsy has been found to be 
permanent. 
The following history sufficiently illustrates this form 
of pressure: 
Q. C. Meanning, aged forty, Company B, 1st Mass. 
Cavalry. Enlisted Sept. 1861. He was previously well. 
In January, 1863, he fell, breaking both bones of the 
right leg. Union took place, with deformity and unusual 
difficulty in locomotion. From April 25th to June 20th 
he walked on two common wooden crutches, and then, 
until July 11th, on one, which he used on the right side, 
leaning heavily upon it. On the last-named day he 
walked a great deal more than usual, and immediately 
after found that the third and fourth fingers were be- 
numbed. The following night he lost partially the 
use of the arm. The axilla felt sore, but there were no 
evidences of any central lesion, or of syphilitic or rheu- 
matic antecedents. 
Since then his biceps regained power, but no other 
muscle had improved up to July 21, 1863. At that time 
his shoulder muscles acted well, except the deltoid, which 
was feeble. The other muscles of the arm were healthy. 
The biceps was feeble; pronation and supination were 134 
INJURIES OF NERVES. 
good; flexion and extension of the wrist were nearty ab- 
sent; the finger motions were all excessively weak. Sen- 
sation was absent in the ulnar side of the palm, wrist, and 
forearm, and nearly absent in the forefinger. In the fore- 
arm muscles, the electric contractility was lessened, and 
was barely present in the abductor min. dig. The axillary 
nerves were not tender on pressure. 
Treatment—The patient was directed to use a cane in 
the left hand, to have a starch bandage as a support for 
the broken leg, douche and faradisation daily to the fore- 
arm. The relief was very rapid and complete; so much 
so that within two months he recovered the full use of the 
weakened muscles. Sensation returned more slowly, but 
finally was aided by faradisation of the dried skin. He 
was put on guard duty after four months’ treatment, but 
had then, I believe, some slight numbness in the fourth 
finger and ulnar palm. CHAPTER VI. 
SYMPTOMATOLOGY OF NERVE LESIONS. 
The character of the symptoms varies but slightly in 
the different forms of nerve injury. If we had presented 
to us a hand which was suffering from wound of the me- 
dian nerve, there would be nothing in the symptoms to 
show how they were caused, and the hurt might have 
been due to gunshot wound, to incision, to a puncture, or 
to a simple contusion of the nerve. Moreover, the symp- 
toms in nerve wounds rise into the highest practical im- 
portance as regards treatment, and are so much alike in 
all regions of the body, that it seems better to deal wTith 
them collectively than to describe, in tedious detail, the 
nerve wounds'of each limb, and so to be forced into 
endless repetition of the same particulars in numerous 
cases. 
I have chosen, therefore, to treat of the symptoms in 
successive chapters, and to reserve for separate study the 
wounds of such nerves as, by position or function, de- 
mand peculiar consideration. 
Local symptoms.—The immediate symptoms of nerve 
injury are local and general. I have questioned hundreds 
of men who have been shot through nerve trunks, and 
have found a curious diversity as to their first sensations. 
Usually the man thinks he is struck with a stick or stone, 
and angrily accuses a comrade of the trick. Others suf- 
fer instant and intense pain, which is felt at the wound 
(135) 136 
INJURIES OF NERVES. 
and down the nerve tracks. A clever sergeant, a Cana- 
dian by birth, described bis first pain as like that which is 
felt when a cricket-bat carelessly held is struck by a swift 
ball. This feeling of numbness, with tingling pain, is 
common in cases of slight nerve wounds or contusions. 
Even when the primary pain is severe, it is lost in a few 
moments. Indeed, cases of pain which arise at the mo- 
ment of the hurt, and continue steadily, are very rare. 
I recall but one instance, that of a man who said he 
had burning pain in the hand from the instant he was 
hit. 
In the book on Gunshot Wounds and Injuries ofKerves, 
by Drs. Morehouse, Keen, and myself, forty-three cases 
of nerve wounds are analyzed in regard to the immedi- 
ate symptoms. To these I now add forty-eight. Of the 
ninety-one so brought together, rather more than one- 
third had no pain, and many did not know they were shot 
until weakness or the sight of their own blood betrayed 
the presence of a wound. 
We may suspect that the difference as to pain in these 
cases depends upon the rate of motion of the ball, which, 
if slow, would be more likely to cause pain. Indeed, we 
all know from personal experience how little pain is given 
by a sharp cut made quickly, and it has even been pro- 
posed by Dr. Richardson to utilize this fact in order to 
open abscesses without pain. I presume that a man in a 
high state of excitement would be less apt to know of his 
being wounded, and this is certainly the case; but there 
are also men who have been shot through the brachial 
plexus while quiet spectators, and have first been informed 
of it by the flow of blood. 
Other and rare cases have remote pain, and none at the 
point hurt. I have seen an instance where the ball, hav- 
ing traversed the inner and upper region of the thigh, 
partly divided the sciatic nerve. The pain was altogether SYMPTOMATOLOGY OF NERVE LESIONS. 
in the testicle, which was retracted during several 
hours.* 
For reasons not altogether clear, some neck wounds 
cause at the moment horrible pain at the insertion of the 
deltoid, which may possibly be due to a sudden spasm 
of this muscle. Commodore Stembel, whose case I have 
elsewhere related,f was shot in the right side of the neck, 
and had pain in both arms. Another officer, struck by a 
ball in the right thigh, felt pain only in the left limb, and 
throughout suffered most in that part. 
Where a nerve of mixed function is slightly injured 
by contusion, the first impression is most felt by the 
sensory branches, and any motor loss is apt to be due to 
secondary changes. In graver lesions, as by bullets, 
sensation and motion are usually both lost at first, 
even if the ball merely grazes the nerve, so that at the 
outset of a case it cannot be known whether a ball may 
have divided a nerve or merely stunned it completel}7. 
At all events, it is common to see the functions return 
ing after what seem to be serious lesions, some parts 
recovering quickly and some more tardily, until at last 
we are able to decide as to what are to be permanently 
damaged, where motion is gone, and where sensation 
is lost. 
* There is a region of skin on the thigh, extending from the groin 
nearly to the knee, and capable of accurate delineation, which has cer- 
tain relations to the scrotum and testicle. Galvanic or mechanical irri- 
tation of this area usually causes retraction of the corresponding testicle. 
It is best seen in young people, and is of value in determining the presence 
or absence of reflex transmissions in the thigh. The sympathetic movement 
and pain in the testicle in the present case were curious illustrations of a 
regional relationship which has perhaps not been elsewhere pointed out, 
and which certainly is not well known or made use of for diagnostic pur- 
poses. 
f New York Med. Jour., 1866. Paralysis from Peripheral Irritation, 
p. 49. S. Weir Mitchell. 138 
INJURIES OF NERVES. 
The following case illustrates unusually well this very 
frequent occurrence: 
Case 16.—A sergeant, wounded in the left side of the 
neck, was placed in our wards within four days from 
the date of his wound, which seemed to have directly 
implicated the brachial plexus. His arm was totally 
palsied as to motion and sensation from the moment he 
was hit; sensation returned within five days. Motor 
power was restored in all the flexor muscles of the hand 
within ten days; and, under three applications of elec- 
tricity, it reappeared in all the other muscles except the 
deltoid and triceps extensor, which never perfectly re- 
gained their functions during very prolonged treatment. 
This temporary though entire loss of motion and sen- 
sation in nerves not absolutely cut across, and, even in 
such as have been untouched by the missile which has 
passed near them, may find, perhaps, some explanation 
in the experiments upon the effects of pressure already 
related. 
In certain cases, the nerve wound, in place of causing 
primary loss of mobility, occasions either sudden muscu- 
lar contraction, followed by instant loss of power, or, in 
very rare instances, long-continued spasm. A soldier, 
wounded in the brachial plexus at Antietam, was obliged 
to ask a comrade to unclasp his rigid fingers from their 
hold upon the musket. A still more singular example 
is that of C., who was shot through the arm at Shiloh, 
and whom I have recently examined. When he was 
shot, the thumb turned inward so violently as to cut 
the skin of the palm with the nail. It remained in this 
position six hours, when the arm was amputated. I recall 
other cases of like nature; but lasting spasm after nerve 
injury is a rare occurrence. 
Early constitutional symptoms ; shock.—One of the gravest 
of the instant consequences of nerve injuries is that which SYMPTOMATOLOGY OF NERVE LESIONS. 
is known as “shock.” This is commonly described as a 
condition in which the patient “becomes cold, faint, and 
trembling; the pulse is small and fluttering; there is a 
great mental depression and disquietude, incoherence of 
speech and thought; the surface becomes covered by a 
cold sweat; there are nausea, perhaps vomiting, and re- 
laxation of the sphincters.”* 
Exactly such as are here described were the symptoms 
of shock which followed nerve wounds. In nearly every 
case there was more or less sudden feebleness, and in 
some there was the most absolute and general loss of 
power, accompanied in a certain number by insensibility, 
probably due to syncope. We have nothing in this direc- 
tion to separate wounds of great nerves from those in- 
volving only muscular and bony parts, and therefore 
minute nerve fibres alone. Gunshot wounds, however, 
present us with certain possibilities which are interesting 
tests of the amount of shock, and which are not available 
in such cases as railway injuries or in any which throw 
ar man down. 
As to what percentage of men wounded through mus- 
cle, or bone and muscle chiefly, sutler from shock, and 
to what degree, I find no mention in surgical works, so 
that I cannot compare my own statistics as to the imme- 
diate shock from nerve injury with that arising from other 
causes. 
This state of shock, so well known to the surgeon, is 
simply a reflex effect of the injury of nerves, large or 
small. In general, it affects in varying proportion all the 
great nerve centres which preside over circulation, respi- 
ration, and voluntary movement, and instantly brings 
about such a condition as follows an overdose of tartar 
emetic. Its symptoms and treatment are alike familiar, 
* Erichsen’s Surgery. Ed. by Dr. John Ashhurst, 1869, p. 121. 140 
INJURIES OP NERVES. 
but there still are certain questions in regard to it which are' 
answered more or less well by my own cases, all of which, 
it should be borne in mind, involved lesions of great 
nerve trunks or plexuses. To obtain a reply to these 
questions, I have taken only the cases of wounds of large 
nerve trunks, and only those of the upper half of the 
body, because the test of sudden fall would be valueless 
as regards wounds in the legs. I have also excluded 
every instance of early and severe hemorrhage, so that 
finally we have left for analysis fifty-six cases. 
If we examine these with reference to the site of 
wound, the amount of shock, as indicated by the number 
who fell at once, and of those who fell insensible, and the 
presence of pain in such as were able to feel, we reach the 
following conclusions: 
Those struck were nearly all of them actively en- 
gaged in loading, or were charging or retreating. From 
the effects felt by these men as compared with what was felt 
by the remainder who were not in close action when hit, 
and also not in movement, it would appear that pain is 
more commonly an instant symptom of nerve wound when 
the man is inactive, since nearly all of these had pain when 
wounded, while of the remainder about one-half had no 
pain. Yet although such was the case, a third of the latter 
felt some intimation of their being hurt, in the form of a 
sudden numbness or other sensation, which they persisted 
in describing as not painful. These statements are there- 
fore contradictory of the usual surgical opinion in regard 
to the instant pain arising from nerve wounds. Indeed, 
only two of the fifty-six cases had pain which could be 
called acute. 
Taking all of the fifty-six cases, and studying them as 
regards shock and seat of wound, we get these curious 
replies. There were twelve wounds of the brachial plexus 
in the neck. SYMPTOMATOLOGY OF NERVE LESIONS. 
141 
Of these, two fell senseless; seven fell with more or 
less confusion of mind; and three walked away. 
The same nerves were wounded in the axilla ten times. 
Of these, again, two fell insensible; four fell without 
loss of sense; and four were able to walk away. 
There remain thirty-four cases of wounds of the brachial 
nerves, including the ulnar, radial, musculo-spiral, and 
median. Of these, six fell senseless; six fell, having their 
senses; and twenty-two were able to walk away. 
The neck wounds, owing to which nine out of twelve 
fell, would seem to cause greater shock than arm wounds, 
from which only twelve out of thirty-four fell. 
Taking the whole number, regardless of analysis by 
regions, for which, indeed, they seem scarcely numerous 
enough, we have of nerve lesions confined to the brachial 
plexus and its ultimate nerve trunks, fifty-six histories. 
Of these, at the instant of the wound, ten fell insensible, 
and seventeen dropped without loss of consciousness. 
Twenty-nine were able to walk away, either at once or 
after a few minutes, but nearly all of these (twenty-two) 
felt a certain loss of power at once or very soon. It is 
difficult, however, to carry the analysis further, because 
in a minute or two the flow of blood and the emotion, 
owing to knowledge of the loss of ability to move, come 
into the case, and are hard to eliminate as causes of 
secondary influences affecting the general result. So far 
as I have carried the conclusions, I believe them to be 
worthy of trust. While most cases of nerve wounds ex- 
hibit more or less shock in the form of cardiac feeble- 
ness and general arterial spasm, in a smaller number 
we meet with what might be called a localized expression 
of the influence of the neural lesion. Thus, in place of a 
general impression upon vaso-motor and cardio-motor 
centres, we sometimes see the shock limited to a dis- 
turbance of ideational or emotional centres, or to a single 142 
INJURIES OF NERVES. 
sensory ganglion, or to a group of spinal-motor cells. In 
certain instances, these results are temporary, in others 
they are lasting, and then constitute what is usually called 
reflex paralysis, but which I should prefer to term, where 
it affects muscular motion, paralysis from peripheral 
irritation. 
Shock, then, is reflex disturbance, or, in some cases, 
paralysis of centres. Why in one case the cerebrum 
should suffer, in another the heart, and in a third the mo- 
tor centres of the leg or arm, is as yet inscrutable. A 
ball crushes a nerve, and the tremendous shock instantly 
propagated to the spine falls ruinously upon some one 
of the numerous ganglia through which it travels. Is 
this because it finds a weak point, or is it that conduction 
checked somewhere causes at that spot destruction from 
dangerous accumulations of nerve force? Tempting 
analogies here open to certain electrical phenomena, but 
as yet we lack such exact knowledge as would justify 
further inferences. 
Theories of shock. — At the present time vaso-motor 
agencies are called upon to explain every phenomenon in 
disease, and for most pathologists to-day all reflex injuries 
seem to be due to vasal spasm or vasal palsy in the 
centres affected. Elsewhere,* together with Drs. More- 
house and Keen, and since then in a longer essay,f I 
have stated the objections to Brown-Sequard’s famous 
theory, which explained reflex paralysis by vascular 
spasm and consequent insufliciency of nutritive supplies. 
Gull,| Jaccoud,§ and the author, have all alike insisted 
that permanent spasm was scarcely conceivable, or, at 
all events, that we had no distinct evidence of its possible 
* IT. S. A. Circular No. 6. Eeflex Paralysis. 1864. 
f Paralysis from Peripheral Irritation. New York Med. Jour., 1866. 
J Med.-Chir. Trans., vol. xvii. Dr. Gull. 
$ Les Paraplegies. Jaccoud. SYMPTOMATOLOGY OF NERVE LESIONS. 
143 
existence in the centres; while we have also pointed 
out that the reception of Brown-Sequard’s theory would 
necessitate belief in subsequent palsy of vessels and 
vasal nerves as a far better explanation of the central 
results of reflex irritations. “ Thus the stern physiological 
law of rest after labor, of relaxation after contraction, 
stands in the way of any idea which presupposes long- 
continued vasal spasm;”* and against it also are a 
number of satisfactory objections to the experiments 
upon which its author relied for its support. Moreover, 
it has been loaded with needless conditions, which make 
its acceptance still more difficult, since he has insisted 
that in reflex palsies the centres affected exhibit no lesion, 
which seems inconceivable in the presence of either vas- 
cular spasm or palsy, if these be long continued. Per- 
haps if this justly distinguished observer had more freely 
explained himself, some of these objections might have 
1-ess weight, since he has been kind enough to assure me, 
after careful reading of my criticisms, that our ideas dif- 
fer in reality less than I had conceived them to do. 
Another theory supposes that in the ordinary instances 
of long-continued irritation of a part, the reflected impres- 
sions falling — why we know not — on some particular 
centre, either keep it in a state of excitement, resulting in 
pain or muscular spasm, or else wear out or suddenly ex- 
tinguish its excitability so as to paralyze its dependent 
muscles. It becomes us, however, to be cautious as to 
the cases we include in this category, since science is 
daily opening new and different ways of accounting for 
many phenomena which have hitherto been confidently 
termed reflex. It is common, for example, so to explain 
cases of palsy of a leg remotely following a cut, a hurt 
nerve, or a wounded or crushed toe-nail. Yet, as we shall 
* Paral. from Periph. Irrit., p. 33. 144 
INJURIES OF NERVES. 
see, many of these are simply examples of disease propa- 
gated along the nerve first involved to the main trunk, 
and thus involving other branches. 
Ho such objections apply to the histories of palsy re- 
ported by my colleagues and myself, since in them the 
wound of one part was instantly followed by loss of power 
in a remote region. 
These, also, I prefer to explain by presuming that the 
shock had suddenly exhausted some ganglionic centre, 
and thus palsied its related muscles. This view was set 
forth by us in March, 1864, and more elaborately, though 
not more distinctly, by Jaccoud, in December of the same 
year. We then remarked that “either the shock of a wound 
causes paralysis of vaso-motor nerves and sequent conges- 
tion, with secondary alterations, or that it destroys directly 
the vital power of a centre. How, there is no reason why, if 
shock be competent to destroy vitality in vaso-motor cen- 
tres or nerves, it should be incompetent so to affect the 
centres of motion or sensation.” Indeed, it appears in- 
comprehensible that any vasal spasm aud consequent 
relaxation could be competent to instantly and perma- 
nently paralyze a whole limb, while sudden deaths from 
shock seem also explicable in no other way than by abso- 
lute exhaustion of nerve force in some vital centre. 
Explain them as we may, however, there exists a set of 
rare cases, for the full records of which I must refer to 
the essays quoted. I give here a very brief ab- 
stract of each case, with some important additions: 
Case IT.—Gunshot wound of right wrist-joint, injuring 
the ulnar and median nerves, and causing cerebral excite- 
ment. The patient, a colonel, ran along the line of his 
regiment, “half-crazed,” in a state of wild excitement, 
and presently fell insensible,—not from loss of blood. 
Case 18.—An officer, wounded in the heel, was thrown 
instantly into a condition of the utmost trepidation, and SYMPTOMATOLOGY OF NERVE LESIONS. 
145 
behaved like an insane person. His character for courage 
was undoubted, and a court of inquiry, for which he 
asked, cleared him on the surgical evidence. 
Case 19.—A private, shot through the brachial plexus, 
became wildly excited, crying murder repeatedly, and 
accusing those near him in the ranks of having shot him. 
He did not fall. 
Case 20.—An officer, shot through the right median 
nerve, was helped away to the rear, talking somewhat 
incoherently about matters foreign to the time and scene. 
He was very feeble, but lost little blood, and had not the 
least remembrance of having been shot, or of any event 
which followed within an hour afterwards. 
Such cases as these are examples of shock affecting 
variously the emotional or intellectual organs. Legouest, 
in his “ Surgery-of the Crimean War,” p. 219, describes 
them as not uncommon. 
As I have had occasion to repeat, the shock of nerve 
wounds commonly weakens the heart; but in one case it 
merely interfered with its rhythm. 
Case 21.—G. A., a wagonmaster, was shot through the 
left ulnar nerve. This trunk was totally destroyed, as 
well as the ulnar artery, and years afterwards he consulted 
me to learn whether the resultant loss of sense and motion 
could be again restored. When struck, he felt a sharp 
pang in the hand, and had at once great agitation of the 
heart; at all events, this was so annoying as to be for some 
days the dominant symptom. With occasional returns it 
grew gradually better, and when seen by me he had long 
ceased to feel it. 
In the following cases a ball wound caused paralysis 
elsewhere : 
Case 22.—R. S. Ball wound of right neck, probably 
involving no important nerve directly; fracture of hyoid 
bone; reflex paralysis of left arm; probable reflex pa- 146 
INJURIES OF NERVES. 
ralysis of right arm ; early recovery of left arm ; more 
remote} and nearly complete recovery of right arm. 
Case 23.—J. D. Flesh wound of right thigh, without' 
injury of large nerves; complete paralysis of all four 
limbs; left arm recovered quickly ; the other limbs slowly; 
final development of myelitis. 
Case 24.—W. W. Wound of right thigh, with proba- 
ble injury to sciatic nerve; partial palsy of right leg; re- 
flex paralysis of right arm, which recovered rapidly. 
Case 25.—A sergeant, shot through the right testicle. 
He fell, without pain, except in the back, and soon be- 
came senseless. Partial loss of power in right foot; no 
loss of sensibility. 
Case 26.—I). K. Gunshot wound of right thigh; direct 
lesions of crural nerves; loss of motion and sensation; 
reflex paralysis of right arm as to motion. 
In two remaining cases, wounds of one leg seemed to 
the patient to be truly in the other; and in one there was 
a space of anaesthetic skin on the uninjured side, sym- 
metrically related to the site of the wound.* 
Other but more doubtful cases of reflex paralysis have 
been seen by me, but these I have hesitated to put on 
record. It will be observed, also, that of the twelve cases 
here given in abstract, only six involved injury to large 
nerve trunks; and in a seventh, all the nerves of an im- 
portant organ, the testicle, must have been instantly de- 
stroyed. 
* In Case IV., Hutchinson’s Series, p. 313, the median and ulnar nerves 
being injured, there was pain in the unhurt hand. Pirogoff, p. 384, has 
a similar instance from injury to the right brachial plexus. CHAPTER VII. 
REMOTE SYMPTOMS. 
Tetanus—chorea.—We have thus disposed of the early 
symptoms, local and general, which occur when a nerve 
trunk is wounded. The reunion and regeneration of the 
nerves have been already described : and for the rest, 
wounds involving large nerves heal as do others, and in- 
volve no greater constitutional dangers. The local changes 
in motion, feeling, and nutrition are what most interest 
us in these wounds, and which, indeed, continue to do so 
long after the wound has been healed. 
The only constitutional conditions to which they may 
give rise during this process, or soon afterwards, are 
tetanus and chorea. There is a prevalent belief that 
tetanus is more apt to arise when large nerves are slightly 
hurt than on other occasions; but although there are on 
record many cases where this terrible malady has followed 
the inclusion of nerves in ligatures, in the mass of tetanic 
histories the. causal irritation has arisen in the extreme 
distribution of nerves, and where there has been no proof 
of precedent injury to large trunks. Were it otherwise, 
I must more often have seen tetanus, whereas in two hun- 
dred recorded instances of wounds of great nerves which 
passed under my eye during the war, not a single case 
of lock-jaw was seen, although in perhaps one-half the 
injuries were recent, and we actually witnessed a part of 
the process of healing. In fact, the tendency towards 
irritation, resulting in spasm, seems to increase as the 148 
INJURIES OF NERVES. 
nerves divide and approach the skin. Brown-Sequard 
succeeded once in causing tetanus, by leaving a rusty 
tack in the foot of an animal. I have never been able to 
get this result by any method, nor in some seventy 
sections of wounds of nerves in animals have I ever 
encountered it. 
Chorea, a still rarer consequence of nerve wounds, is 
a very uncommon result of any wound, although I have 
met with such cases, especially one in an adult, where 
the ankle was slightly injured by a ball. Dr. Packard* 
reports a case of chorea from injury to the terminal 
filaments of the median nerve in the thumb. Exsection 
of a sensitive point brought about relief and cure, which 
all previous means had failed to effect. 
I have seen no example of chorea from wounds of 
large nerve trunks, but I have several times been called 
upon to treat this malady in the stumps left by amputa- 
tions of the arm. Here, however, it is one of the more 
remote consequences of changes in the divided nerves, 
and is excessively rebellious to treatment. Beginning in 
the stump, it is apt to be propagated to more distant parts, 
so as finally to assume, in certain cases, a unilateral char- 
acter. I shall elsewhere have occasion to speak of the 
tendency of muscles in stumps to twitch from excitement 
or changes of weather, and to obey irregularly orders 
directed by volition to parts in the lost limb. 
Later local symptoms.—Long after a nerve has been 
bruised or wounded, there is apt to occur in the skin or 
muscles to which it is related a double series of most un- 
manageable symptoms—the one due to division of nerve 
fibres and absence of nerve force, the other to irritations 
of nerve fibres which are still more or less entire, and to 
consequent disturbances of the nutrition and functions of 
* Am. Jour. Med. Sci., April, 1870, p. 347. REMOTE SYMPTOMS. 
149 
the connected tissues. These irritations are in some cases 
of inflammatory birth, and in others purely mechanical, 
hut in all probability they result in the propagation to the 
connected parts of a succession of interrupted waves of 
force, which give rise to many of the phenomena and 
appearances with which these cases present us. A part 
of the symptoms is due to loss of nerve force, a part to 
irregular nerve force; and I use this term because we are 
not clear as to the nature of the abnormal influences thus 
exerted. The separation of these two causes of evil in 
nerve wounds is not always easy, so that an}’ one who sees 
many nerve injuries will constantly be called upon to ad- 
mit that in numerous instances we cannot tell whether a 
given result be due to one cause or the other, since, as 
regards the influence of the hypothetical nutritive nerves, 
vaso-motor and all other, upon tissues, we know so little 
as to be unable to decide whether this or that condition 
of tissues may be caused by a non-supply of their normal 
nerve impulses, or by some irregularity in these. We have, 
indeed, as yet, no good test which shall serve us to make 
this distinction as clear as it is in wounds of musculo- 
motor nerves, in which nerve section causes palsy, and 
nerve irritation some form of spasm. Yet interesting as 
these questions may be, their settlement does not affect 
either our clinical prognosis or our therapeutic methods. 
In considering the local symptoms which follow nerve 
wounds and endow them with an interest belonging to no 
other lesions, I shall treat, first, of the nutritive changes; 
second, of altered states of sensibility; and lastly, of the 
various causes which affect motility and mobility. 
Trophic changes.—When, as rarely happens, an injury 
has totally destroyed a portion of all of the great nerves 
of a limb, and there has been no subsequent reunion, the 
related tissues undergo atrophic changes which are very 
remarkable. The muscles waste away, the areolar tissue 150 
INJURIES OF NERVES. 
disappears, the skin becomes dry, ragged, yellowish or 
brown, and rough; the nails and hair degenerate, while 
the veins shrink and the arterial pulse grows feeble. 
Lesser nerve injuries produce, of course, muscular atro- 
phies bearing a proportion to the fibres wounded or cut. 
Where a missile has divided a nerve, wholly or in part, 
these changes begin in the connected muscles with a 
slight but almost immediate loss of tension, so that the 
muscle feels flabby and relaxed. 
This is certainly the first notable alteration in a muscle 
the nerves of which have been severed. It is so percepti- 
ble, within a day or twTo of the injury, that in some cases 
it is possible to tell, by handling the part, what muscles 
are thus isolated and what are not. Within a few hours 
there is, in the disordered muscle, some loss of power to 
move when faradised, and the difficulty increases day by 
day, until finally it ceases altogether to respond to this 
form of stimulation. For a much longer time, perhaps 
even for weeks or months, the same muscle may move 
more or less readily when traversed by a current of twenty 
to forty galvanic cells, while it is also noticeable that 
mechanical irritation may produce contractions long 
after induced currents have ceased to possess any such 
power. 
The pathological changes which accompany this func- 
tional deficiency have been frequently described as fatty 
degeneration; but they scarcely deserve this description. 
The following extract from Vulpian so precisely corre- 
sponds to the alterations which I have myself seen and 
studied, as to require no additions : 
“ Muscular atrophy from nerve section is characterized 
by a considerable reduction in the diameter of the primi- 
tive muscular bundles, accompanied in a few localities by 
granular fatty changes, with total disappearance of cer- 
tain fibres. In the early stages of alteration, the primi- REMOTE SYMPTOMS. 
151 
tive fibres appear to be segmented, the muscular substance 
persisting in some places and being absent in others. At 
the same time, we observe the formation of a more or less 
considerable quantity of fat vesicles in the connective 
tissue which separates the secondary bundles of fibres, 
and much more rarely between the primitive fibres. Mul- 
tiplication of the nuclei and hyperplasia of the general 
connective tissue of the muscle are also observed, while 
the vessels suffer only a loss of calibre, 'without other 
changes.” 
Atrophy from complete nerve division is pretty surely 
followed by contraction of muscles, bjut I have been 
unable to determine the time at which this begins, and 
the stage of atrophic change to which it is related. It is 
usually a remote consequence of complete division of a 
nerve, and is, perhaps, the worst of all the signs which 
foretell a hopeless loss of function. It sometimes happens 
that extreme atrophy takes place without consequent con- 
traction ; but we may then suspect, enough of time hav- 
ing elapsed to admit of the change, that the nerve com- 
munications have been in part restored, so as, in such a 
case, to allow of successful treatment. I have said that 
usually the shortening bore a strict proportion to the 
amount of wasting; but to this there is another exception 
besides the one above mentioned. In a few rare cases, 
the atrophy being but slight, the contraction has seemed 
to be excessive. I am unable to explain this to my satis- 
faction. The force with which the failing muscle contracts 
reminds me of the power with which certain scars shorten, 
and results, as I shall elsewhere point out, in ruin to the 
usefulness of the uninjured muscles, and in subluxation 
of the joints concerned. 
Influence of nerve injuries upon the nutrition of the skin and 
its appendages.—As in the muscle so in the skin, the ner- 
vous lesions may fall only on the functional innervation, or 152 
INJURIES OF NERVES. 
may alight upon this and on the nutrient system of the 
skin at one and the same time. I have yet to see a dis- 
tinct case of nerve wound affecting the latter singly, with- 
out sensory or motor disturbance; 
The mode in which nerve wounds attack the cutaneous 
nutrition, whether directly, by irritations of fibres leading 
to the part, or reflectively, through the centres, and by 
uninjured filaments upon the skin, is often, nay, gener- 
ally, difficult to determine; but since in total nerve sec- 
tion we more rarely observe such grave disasters to skin 
nutrition as follow partial lesions, it is likely that re- 
flected irritations have their share in the mischief; yet 
there is reason to believe that in one large class of skin 
disease arising out of nerve wounds, the irritation is direct 
rather than of reflex parentage. 
The nature of the irrigation which arises in nerve wounds 
is somewhat doubtful. It is very rare that any of the 
peculiar nutritive changes occur early. They are more 
liable to arise with the inflammatory state into which most 
wounds are apt to fall, or they follow the injury even 
more remotely, as in contusions. We may, therefore, 
suspect neuritis or sclerosis as frequent causes of mischief. 
In one case I saw a sudden access of inflammation in a 
healing wound over the injured median nerve determine 
an immediate outbreak of neuralgia, ulcerated matrices 
of nails, and vesicular eruption ; while in another, a 
wound of the radial, an attack of erysipelas brought about 
causalgia (burning pain) and glossy skin, with eruptions, 
the patient having previously only some loss of motion 
and sensation. I have already stated that complete sec- 
tion of the nerve of a limb caused general atrophy, with 
cedema, and finally discoloration of the dry and thickened 
skin, the ragged epithelia hanging in patches. Some of 
these conditions are, no doubt, due to want of use. 
Cases of this kind are, however, very rare, and do not REMOTE SYMPTOMS. 
153 
exhibit the horrible lesions which in animals are apt to 
follow complete nerve sections. Certain instances of local 
ulceration, consequent upon entire nerve sections, have 
been recorded; but, on the other hand, Hutchinson and 
Paget both describe the ready healing of wounds in 
parts so situated, of which I have seen many examples. 
The former author speaks, also, of the reproduction of 
nails in a finger having no central nervous connections. 
There is, therefore, nothing in the loss of innervation to 
restrain cicatrization. A remarkable case in point is 
the ease and speed with which we can often heal the 
ulcers caused by pressure in paralyzed persons, when the 
parts have been put into conditions favorable to healing. 
Slight nerve injuries from pressure, contusion, and par- 
tial division by ball or blade, occasion a variety of singular 
symptoms, which had been little studied before my col- 
leagues and myself saw at Turner’s Lane Hospital an 
unequaled collection. 
Cutaneous eruptions.—At some time in the history of a 
nerve injury it is common to see certain forms of erup- 
tion, which are herpetic, vesicular, or in the shape of 
bullae. Iu our own experience we saw numbers of erup- 
tions which, as a rule, were most sure to be met with in 
the cases of greatest irritation, and which usually assumed 
the appearance of small vesicles. 
Charcot* has described a case of Rayer’s, of gunshot 
wound of the thigh, which resulted in neuralgia, and in 
the production at the painful spots of repeated crops of 
herpes. In a note to Charcot’s cases, Brown-Sequard men- 
tions a contusion of the internal cutaneous nerve of the 
arm, also followed by herpes ; and there exist numerous 
histories of like eruptions consequent upon blows affect- 
* Journal de Phys., 1859, p. 108. 154 
INJURIES OF NERVES. 
ing certain regions of skin. Bullte resembling those of 
pemphigus occur in other instances. In one of Charcot’s* 
cases, abscesses, or the incisions needed to open them, 
injured the nerves of the arm, and resulted in loss of sen- 
sation, partial paralysis, atrophy, neuralgia, and finally, 
late in the case, in a peculiar eruption, chiefly about the 
joints of the index, medius, and ring fingers. Bullte 
formed in a few hours, “grew as large as a nut,” and, 
breaking, disclosed a quickty-healing ulcer. 
A case is also given by Raynaud,f in which the ulnar 
nerve was compressed at the elbow, with the result of 
successive groups of phlycttenula seated exactly on the 
nerve track. They were full of bloody serum, and left 
no ulcers when they broke. In these cases there was no 
inflammation, but in those related by Earl, Romberg, and 
KuhlJ there was inflammation about the bullae. In a case 
of nerve injury by pressure at the wrist, I saw the thumb 
rapidly covered on the fourth day by a large bulla, and 
looking as if blistered. Mr. Hutchinson§ reports a similar 
instance where there were marked inflammation, bullae, 
and ulceration; and it would be easy to extend the list if 
this were desirable. 
I have already remarked that in total division of nerves, 
the injuries from blows or pressure to which the part may 
be afterwards exposed are apt to result in ulcers, which 
require only careful and judicious treatment to enable 
them to heal. But in partial nerve sections superficial 
ulcers sometimes form without obvious mechanical causes, 
and, according to my own experience, such ulcers usually 
result from previous bullte, or, as I have seen repeatedly, 
* Mougeot, Rech. sur quelques Troubles de Nutrition consecutifs aux 
Affections des Nerfs. Paris, 1867, p. 36 et seq. Also Samuel, op. cit. 
f These de Paris, 1862, p. 156. 
$ Samuel, Die trophischen Nerven, p. 189. 
$ Clin. Lects. and Reports London Hospital, p. 314. REMOTE SYMPTOMS. 
155 
and as Hutchinson relates, they assume the form of whit- 
lows, which are painful or not, as they chance to be in 
anaesthetic or hypenesthetic regions. The vesicular dis- 
eases of the skiu which, in our experience, followed nerve 
wounds by missiles, we described as eczematous, a term 
which has been criticised Hanfield Jones and Charcot. 
In reality, these eruptions were somewhat peculiar, and 
more like eczema than herpes. In a few cases they ap- 
peared upon healthy skin, but usually made one of the 
features of that singular condition of atrophied skin with 
burning pain which followed a remarkably large propor- 
tion of gunshot wounds of nerves. The eruption con- 
sisted of small, scattered, acutely-pointed vesicles, full of 
a thin, serous tiuid. On the healthy skin they were larger, 
and dried up without sequelae ; but when situated on the 
thin and altered teguments, they left behind them minute 
ulcers, which horribly increased the itching or the burning 
so constantly present. 
It was somewhat rare to see any case of glossy skin, 
especially with causalgia, unattended by vesicles; but 
these were apt to come and go in successive crops, and 
we soon observed that when present the burning pain 
was lessened,—a fact which our patients also recognized. 
Asa rule, the eruption was widely spread over the affected 
skin, and was not gathered into groups. 
Atrophic conditions of the skin.—Previously to the Report 
from the United States Army Hospital for Nervous Dis- 
eases* Mr. Paget had described briefly, but forcibly, a 
peculiar shining, glossy state of skin, the accompaniment 
of certain intractable neuralgias.* The earliest 
of this form of pain from nerve wound is, however, to be 1 
met with in the classical case of a portion of ball im- 
bedded in the radial nerve which Mr. Alex. Denmark 
* Paget’s Cases, Med. Times and Gazette, March 26, 1864. 156 
INJURIES OF NERVES. 
reported in 1813.* The patient described the sensation 
of pain “as beginning at the extremities of the thumb 
and all the fingers, except the little one, and extending 
up the arm, to the part wounded. It was of a burning 
nature,” he said, “ and so violent as to cause a continual 
perspiration from his face. lie had an excoriation on the 
palm of the hand, from which exuded an ichorous dis- 
charge. He could not bear to be touched without evincing 
additional torture.” In our wards, we found this remark- 
able form of skin disease associated, as a rule, with a very 
characteristic burning pain, which in most of the cases 
became at length the dominant symptom.f Mougeot, in 
quoting our description, labels the condition as erythema ; 
but no conception of erythema as known to me would at 
all fill up the picture of this extraordinry malady. Since 
we published our history of numerous cases thus affected, 
Hutchinson, Annandale, and others have encountered 
similar instances, but as yet none have appeared which ap- 
proach in severity certain of the examples furnished by us. 
I shall therefore content myself with a somewhat altered 
statement taken from our book, and shall refer the reader 
to the annexed cases and to the chapter on sensation for 
fuller details. 
The state of skin to which I refer is never present 
without burning pain, and commonly the earlier presence 
of this form of neuralgia enabled us to predict the com- 
ing of the skin disease. In no case did it become visible 
short of two weeks, but usually it preceded the healing 
of the wound, and not rarely was to be traced to an out- 
break of inflammation involving the wound. 
The duration of the malady varied from a few weeks 
to years, but in all of the cases I have been able, to follow 
it has either been cured or gradually disappeared. 
* Med.-Chir. Trans., London, vol. iv. p. 48. 
f It was singularly rare in cases of ordinary shooting neuralgic pain. REMOTE SYMPTOMS. 
157 
Mr. Paget describes this state of skin in the following 
language: “ Glossy lingers appear to be a sign of peculiarly 
impaired nutrition and circulation due to injury of the 
nerves. They are not observed in all cases of injured 
nerves, and I cannot tell what are the peculiar conditions 
of the cases in which they are found, but they are a very 
notable sign, and are always associated, I think, with dis- 
tressing and hardly manageable pain and disability. In 
well-marked cases, the fingers which are affected (for this 
appearance may be confined to one or two of them) are 
usually tapering, smooth, hairless, almost void of wrinkles, 
glossy, pink, or ruddy, or blotched as if with permanent 
chilblains. They are commonly also very painful, especi- 
ally on motion, and pain often extends from them up the 
arm. In most of the cases, this condition of the fingers is 
attended with very distinct neuralgia, both in them and 
in the whole arm, and its relation to disturbance of the 
nervous condition of the part is, moreover, indicated by 
its occasional occurrence in cases where neuralgia con- 
tinues after an attack of shingles affecting the arm. In 
two such cases I have seen this same condition of the 
fingers well marked, and only very slowly subsiding, and 
seeming unaffected by the ordinary treatment of neural- 
gia.” The following quotation from the work of Drs. 
Morehouse, Keen, and myself, describes the malady as it 
appeared in numerous cases in our own wards: 
“ Glossy skin.—The skin affected in these cases was 
deep-red or mottled, or red and pale in patches. The 
epithelium appeared to have been partially lost, so 
that the cutis was exposed in places. The subcuticular 
tissues were nearly all shrunken, and where the palm 
alone was attacked, the part so diseased seemed to be a 
little depressed and firmer and less elastic than common. 
In the fingers there were often cracks in the altered skin, 
and the integuments presented the appearance of being 158 
INJURIES OF NERVES. 
tightly drawn over the subjacent tissues. The surface of 
all the affected part was glossy, and shining as though it 
had been skillfully varnished. Nothing more curious 
than these red and shining tissues can be conceived of. 
In most of them, the part was devoid of wrinkles and 
perfectly free from hair. Mr. Paget’s comparison of chil- 
blains is one which we often used to describe these ap- 
pearances ; but in some instances we have been more 
strikingly reminded of the characters, of certain large, 
thin, and highly-polished scars. 
“ Where a single nerve, as the ulnar, had been attacked, 
the described state of skin was seen only in its ultimate 
distribution; but in other instances of more extensive 
nerve injury, the central palm suffered, or a single finger, 
or the pulps of all of them. In others, the palm or 
fingers were dotted with islets of thin and red and glossy 
skin. The dorsum of the hand, as a rule, was in that' 
member the part least subject to the alteration, while the 
dorsum of the foot was in that region the part most liable 
to suffer. Do the greater functional endowments of the 
palm of the hand, as compared to the sole of the foot, 
account for this preference ? 
“Eczema.—A very constant feature of this state of skin 
was the occurrence of eczematous eruptions, which ap- 
peared as minute vesicles thickly scattered over the thin 
and tender cutis, or else showed themselves in successive 
crops, of larger vesicles on the skin about the altered 
parts, with usually a preference for the portions which 
lay nearer the trunk. 
“In some patients this symptom was absent; in others, 
it was never wholly lost, but varied in amount; while in 
a small number it came and went, being absent for weeks 
at a time, and then returning. It was also remarkable in 
these latter, that recurrence of the eruption gave ease to 
certain painful symptoms to be presently described, or, REMOTE SYMPTOMS. 
159 
to speak more cautiously, when the eczema came back 
the pain declined.” 
Since our report, Mr. Annandale* has published a 
very interesting history of wound of a finger with tender 
cicatrix, followed by glossy redness of the skin of the 
same hand, and finally of the opposite hand. Mr. Syme 
removed the finger, which soon relieved the hand first 
involved, but was succeeded by swelling and increase of 
pain in the other hand. The history, unfortunately, ends 
here, and there was no microscopic examination of the 
portion of nerves removed. This is especially to be re- 
gretted, because of the mystery which hangs over the 
production of this form of mal-nutrition of skin and its 
accompaniment of burning pain. I have never seen in 
these cases any distinct redness or swelling upon the 
opposite side, although in severe examples the sense of 
burning and the hypersesthetic state of the skin was apt 
to affect first the symmetrically related member, and then 
other regions or the whole surface. In a single instance, 
the unwounded limb was attacked by a vesicular eruption 
like that which existed on the other palm. Before leav- 
ing this subject, it were well to notice the fact to which I 
have already called attention,f that glossy skin, with 
causalgia, may follow central disease, as in the following 
very interesting case, which was probably an example of 
what it is now the fashion to call “ sclerosis” of the antero- 
lateral column of the spine. That there may also have 
been alterations of nerve trunks, I cannot, of course, 
deny. Charcot has shown that, both in old spinal sclerosis 
and in cerebral palsies, affections of extra central neural 
fibres are not uncommon, so that the present case was 
probably an extreme example of similar disease. 
* Malformations of the Fingers and Toes. London, 1866, Case 35. 
+ San. Com. Kept., p. 429. 160 
INJURIES OF NERVES. 
Case 27.—Intense neuralgia and motor palsy of legs, with 
contracted toes and ankles; no loss of sensation; neuralgia of 
arms and hands ; contraction of fingers; no palsy of upper 
limbs ; hyperxsihesia of palms ; causalgia, and glazed redness 
of ulnar side of palms. October 19, 1865. Mrs. S., aged 
fifty-two, twice married, has had no children, and never 
was pregnant. During the latter years of her last mar- 
riage, and after her husband’s death, she had a good deal 
of distress and annoyances of various kinds. In 1859, 
Mrs. S. had a fall, in which she struck the hack of her 
neck. Two weeks later she felt suddenly a dull hut severe 
pain between her shoulders. Within a few this ex- 
tended into the arms, with dragging and tearing pains 
down to the wrists. A few months later the pains attacked 
the legs, and were accompanied by violent cramps. About 
this time she had distinct articulation; but this did not 
endure. The intellect was clear throughout the case. 
The next symptom was feebleness in the legs, which in- 
creased until she ceased to walk. She has since remained 
on a couch or in bed. After a year, as well as can be re- 
called, her feet and hands became contracted. The toes 
were flexed, the feet extended. The fingers became slowly 
flexed to a right angle with the palm, the index-finger 
remaining extended. The thumb was drawn tightly into 
the palm, and the fingers were extended tightly on them- 
selves. Sensation was said to have been normal at all 
times. It is now entire everywhere. On the ulnar half 
of the palm, in both hands, the skin is dark-red, shining, 
and glazed. It is in these parts exquisitely tender to the 
touch, and is the seat of a constant causalgia or burning 
pain. The soles also burn, but are not red nor shining. 
All the motions are limited by the contractions, but there 
does not seem to be any distinct paralysis. The flexors 
of the toes are somewhat atrophied, but still have volun- 
tary motion. Her bowels are always costive, never being REMOTE SYMPTOMS. 
161 
moved without enemata. Urine is passed with difficulty, 
and for some years has occasionally required the use of a 
catheter; it is cloudy, from deposits of urates, and very 
rarely uric acid sediment; it is always acid; the average 
specific gravity of four specimens of mixed urine of the 
whole day was 1025; no albumen or sugar was present. 
Tubercle in left lung, cough, and hectic. These are symp- 
toms only of the last five months. Nutrition—general 
wasting. The great-toes were subject to occasional ulcers 
at their angles during the first two years of her malady. 
The index, medius, and ring fingers on each hand have a 
disease of the matrix of the nails, resulting in a thinning 
and irregular growth of the nails without incurvation. 
The affection of the teeth is very curious. They were 
formerly regular, white, of even length, and touching one 
another. They are now very unequal in length, and 
diverge from one another, so that the space of four lines 
exists between the two anterior upper incisors. They all 
seem to be turned more or less on their long axes, and all 
are of a deep yellow, despite the most assiduous care. I 
should add that none are loose. I do not know that I can 
fully describe the curious appearance presented by this 
patient’s mouth. It strongly impressed me with the idea 
that there had been disease of the alveolar sockets, some- 
thing akin to that which is met with in the matrices of 
certain diseased nails. 
My patient died in November, 1865. To my regret no 
post-mortem examination could be had. 
Alterations of the cutaneous appendages.—The nails and 
hair undergo very curious changes consequent upon nerve 
wounds. After total section the nails are apt to become 
clubbed, and, in rare cases, to suffer from painless whit- 
low. I am unable to say whether or not nail growth is 
for a time arrested immediately after the section of the 
nerve; but in most of these cases it is found at a later 162 
INJURIES OF NERVES. 
stage to be slower than that of the corresponding healthy 
parts, although in no instance have I met with a total ces- 
sation of growth. In lesser nerve wounds, ulceration 
around the nails is common, and often very painful ; but 
in connection with the glossy skin of certain neural lesions, 
we observed peculiarities of nails and hair which we de- 
scribed as follows: 
“ When the depraved nutritive state has lasted for some 
months, the hair commonly disappears from the fingers 
affected, and the nails undergo remarkable alterations. 
They suffer only in the fingers the neural supply of which 
has been interfered with, so that the nails in the median 
distribution may be contorted and those in the little finger 
be unaffected. The alteration in the nail consists of a 
curve in its long axis, an extreme lateral arching, and 
sometimes a thickening of the cutis beneath its extremity. 
In other cases a change takes place which is quite pecu 
liar, and which to us, at least, was new. The skin at that 
end of the nail next to the third finger-joint becomes re- 
tracted, leaving the sensitive matrix partly exposed. At 
the same time, the upper line of union of skin and nail 
retreats into or under the latter part, and in place of a 
smooth edge, is seen through the nail as a ragged and 
notched border. The patient wTho presented these changes 
in the most striking form had also lateral arching of the 
nail, but no longitudinal curving. It was a case of the 
most terrible suffering, from a combination of burning 
pain in the hand and neuralgic pain in the forearm.* 
“ No deformity of the nails in tubercle at all approaches 
that which nerve wounds occasion. Indeed, we think it 
would be possible for one familiar with these cases to diag- 
nose the existence of a nerve lesion from the form of 
these protuberant and oddly-curved ligils. 
“When the nails of the toes have been attacked, and 
they are very rarely so, the curving is less marked, but a REMOTE SYMPTOMS. 
163 
distressing ulceration is apt to occur at their angles, and 
to break out again and again, despite of every care and 
attention.” 
Besides the curious changes here described, the nails 
suffer in nerve wounds other nutritive alterations which 
have been nowhere well delineated. In many nerve 
wounds, where there is only ordinary neuralgia, and not 
glossy skin and causalgia, I have seen the nails clubbed in 
some cases, and in others dry, scaly, cracked, and fragile. 
Occasionally they are very thin, so as to be tender,—atro- 
phied in fact. I have not seen their growth suspended 
by any nerve lesion, as occurs in some fevers, or rarely in 
constitutional syphilis, and even complete nerve section 
does not prevent lost nails from being reformed. In a 
recent case of wound of the ulnar nerve, the nail of the 
little finger was marked transversely by a series of closely- 
set, indented furrows, such as I have since seen but once, 
and that in a case of hemiplegia, now under my care. 
The hair is very apt to desert the red and glossy skin 
surfaces which accompany causalgia. In the case of Mrs. 
S., quoted above, the hairs on the legs were sparse, and, 
under the microscope, the part of the hair nearest the 
skin was ragged, the external cells of the hair being ruf- 
fled up in a remarkable manner. 
In neuralgia or injury of the fifth pair, alterations of the 
hair are common, such as its becoming partially gray after 
an attack, or falling out for a time. 
Mougeot quotes Pouteau* as having seen in traumatic 
neuralgia the hair growing large and hard, with an incon- 
venient tendency to stand erect. Larrey,f whose relations 
of his campaigns are rich in interesting cases, describes a 
like change in hairs springing from hypersesthetic skin, 
* CEuvres posthumes, p. 92. 1783. 
f Larrey, clinique Chir., v. i. p. 200. 1829. 164 
INJURIES OF NERVES. 
and unable to bear the lightest touch. Bellingeri noticed 
the hair as becoming thicker and harder and as growing 
faster than elsewhere; while yet more singular is the his- 
tory which Hamilton* relates on the authority of Cramp- 
ton. A lancet wound was followed by remarkable symp- 
toms, probably due to neuritis affecting an hysterical 
temperament. Among other changes in the part, the 
arm became thickly covered with hair. Section of the 
nerve gave partial relief, and finally a cure was obtained 
after an attack of pneumonia, in which the patient was 
salivated. 
Loss of hair after nerve sections is occasionally met 
with in animals, especially rabbits, and it is sometimes 
renewed without reunion of the nerve having taken place. 
Further study is yet needed as to the state of the hair 
and nails, especially the latter, as revealing neural or other 
conditions of disease. Beau has paid most attention to the 
subject, but not in nervous maladies. As one of its diffi- 
culties, I may mention that while after nerve sections 
the nails still grow, I have lately discovered that for 
some time after certain cerebral palsies they do not do 
so.f This observation was made in four instances of 
cerebral palsy, by staining the nails with nitric acid. The 
nails began to grow anew in every case a few days be- 
fore motion returned in the fingers, but the rate of 
increase was for a long time slower than upon the healthy 
side. I have since observed the same facts in embolus 
of the left hemisphere with right hemiplegia. It may 
constitute a new diagnostic difference between central 
and peripheral paralysis. 
The following case is a singular example of the effects 
of a punctured wound of a nerve in a child of hysterical 
* Dublin Jour, of Chemical and Med. Science, March, 1868. 
f Eepts. Phil. Coll. Phys., Am. Jour. Med. Sci., 1871. REMOTE SYMPTOMS. 
165 
temperament. The nail lesions, on account of which I 
have quoted the case here, were very unusual in character. 
I am indebted to Dr. J. C. ISTorris for notes of the earlier 
history of the case. 
Case 28.—D. II., a girl, aged thirteen, of highly nervous 
constitution, applied at my clinic for nervous disease, 
December 5, 1871. 
May 24,1868, while she was playing in the street, a lad 
accidentally ran a small penknife blade into her right 
hand. Dr. Horris supposed that it wounded the median 
nerve at the point w7here the digital nerves are given off, 
because it caused at once decided tingling in the third 
linger. The injury seemed trifling, and gave no further 
trouble until thirty-six hours later, when she became sick, 
and began to sutler excruciating pain in the right hand, 
arm, sternum, and back, with fever, rigors, nausea, and 
slight convulsions, without loss of consciousness. The 
hand and arm were slightly swollen, and the head vras 
drawn backward, while there was also tremor of the jaw 
and dysphagia. She could not bear to be moved, and the 
least jar was intolerable. The treatment consisted in the 
application of ice to the spine, poultices to the hand 
and arm, and full doses of anodynes. After four days of 
acute suffering she improved, and nearly free from 
annoyance until the tenth day, when she began to com- 
plain of burning pain in the injured palm. Meanwhile the 
hand remained slightly swollen, livid, and low in tem- 
perature. At this time all the finger-nails of the hurt 
hand began to turn dark from blood effused under them. 
In a few days they became perfectly black, and their 
growth, although not entirely arrested, was for a time 
retarded. The least touch increased the pain in the 
palm, but a firm pressure did not so much affect it. After 
a good deal of ineffectual treatment, the burning pain 
yielded to repeated blisters made with liq. ammonife fort. 166 
INJURIES OF NERVES. 
At the same time she took iron, quinine, belladonna, and 
good diet, and after a time was induced to exercise in the 
open air. She continued to improve during the summer, 
and three months after the injury was free from pain and 
had good use of the hand and arm. The palm, however, 
remained livid, and was lower in temperature than that 
of the other limb. The nails were normal in form and 
color. At this time Dr. Norris ceased to attend, and, 
upon the return of pain, in September, a homoeopath 
treated the case. During the winter of 1868 and 1869, 
the fingers became contracted, and the hand flexed, the 
palm continuing to suffer with burning pain. These con- 
ditions existed in varying degrees up to March, 1869, 
when the pain grew more severe, and the flexions became 
extreme. Six weeks’ treatment by induced currents en- 
tirely relieved all of these symptoms, which remained 
absent until October, 1871. At this date, the flexions 
recurred, but only when a storm impended, or when she 
was under the influence of strong emotions. 
When the case was seen by me, December 5, 1871, 
I found the fingers normal as to movement. Although 
she complained of weakness in the right arm, the dyna- 
mometer showed its grasp to be stronger than that of the 
left. The median nerve track in the arm wTas normal, 
but in the forearm it was tender, and pressure on it ex- 
cited pain at the seat of wound. The nails were natural. 
Nutritive change in connective tissues.—Affections of the 
connective tissues are common after nerve wounds, and 
are first seen in the shape of oedema, local or general, 
in the limb affected. In looking over notes of one 
hundred and sixty cases of these wounds, I find that 
oedema was apt to come on suddenly and to announce, 
as it were, a subsequent neuralgia. Sometimes the swell- 
ing came and went without obvious cause, and sometimes 
it was very persistent and accompanied with congestion REMOTE SYMPTOMS. 
167 
of the skin. In generalized atrophic conditions of a 
limb, the connective tissue shared the loss which fell 
upon the other tissues, seeming to disappear quite as 
rapidly as they. It is, however, indicative of the difficul- 
ties which surround these cases, that in a single instance 
I have seen a nerve wound give rise to an hypertrophic 
state of the connective tissues. The case is so unusual 
that I have been unable to match it either from my own 
material or from the records of others. Such a condition 
of sclerosis of the areolar tissues is, however, a rare inci- 
dent of spinal myelitis. 
Case 29.—John Graham, Company E, 116th Hew York 
Volunteers. A ball entered three inches below the left 
axilla on the posterior face, and made exit two inches 
below the axilla The arm dropped, and the 
man fell, faint and bleeding freely. It is not easy to tix 
the date of the first hyperplastic change, but quite early 
in the case the first and second fingers and thumb slowly 
enlarged without inflammatory signs, and with slight 
darting pains. After the wound healed, these parts in- 
creased still more and became firm to the touch and 
dark-purplish in tint, the lancinating pains becoming 
more severe. For several months there was also burning 
pain in the fingers and palm, and two months after the 
wound occurred, the skin of the affected parts was shed 
almost entire. 
Seven months after he was shot, I saw and examined 
him through the kindness of my friend Dr. Morehouse, 
in whose service the case at that time was. 
He had loss of the sense of touch and pain in the first, 
second, and lower half of the third finger, as well as in 
the palmar face of the thumb. The index and second 
fingers were moveless, but chiefly because of their size 
and stiffness. The thumb could be stirred slightly. In 
all of these parts there were darting pains, and the skin 168 
INJURIES OF NERVES. 
was dry, scaly, and yellow. The enlargement affected 
principally the thumb and first two fingers, but it also 
involved the back of the hand, which was most developed 
on the radial side, the thumb being more remarkably 
overgrown than the other parts. The ulnar side of the 
palm and the back of the hand were a little cedematous, 
but in the regions above mentioned the skin seemed thick- 
ened, and the tissues were as firm as most fibrous tumors, 
and did not pit upon pressure. Dr. Packard, who also 
saw this patient, pointed out its extremely close likeness 
to elephantiasis. 
Alterations of joints.—Of all the various forms of mis- 
chief wrought by nerve wounds, the most intractable and 
disabling are the curious inflammatory states of joints to 
which we were the first to call attention. 
The relation of rheumatic lesions of joints to neural 
injuries of centres is so interesting in its connection with 
our own observations that I shall be pardoned if I allude 
to its history. 
In 1831, my father, the late Dr. J. K. Mitchell, de- 
scribed* four cases of spinal injury, which were followed 
by inflammations of joints below the point of spine 
affected. Upon these he based a pathogenesis of rheu- 
matism, which connected it with affections of the spinal 
centres. Since then, numerous theories of the cause of 
rheumatism have held sway, each in turn to fall before 
more strict analyses and later facts. In 1864 our demonstra- 
tion of the relationship of joint diseases to nerve wounds 
again called attention to this view of the subject. It re- 
ceived favorable consideration at the hands of Dr. Day,f of 
Stafford, England, in an able volume of clinical histories, 
in 1866, and in the same year was carefully discussed by 
* Amer. Jour. Med. Sci., vol. viii. p. 55. 
f Clinical Histories, Dr. Day. London, 1866. REMOTE SYMPTOMS. 
169 
Ball,* who, without going so far as to consider rheuma- 
tism a neurosis, is plainly at a loss to fasten upon any 
clinical distinction between neuro-traumatic arthritis and 
that due to common rheumatism. 
In 1868 Charcotf published his excellent paper upon 
arthropathies consequent on spinal or cerebral lesions; 
and other facts resembling those which he has related 
have since then accumulated largely.| 
In a certain number of nerve wounds, notably7 most 
often in those of the upper extremities, one or more of 
the joints in the wounded limb become swollen. The 
nature of the injury does not seem to influence the case, 
as I have seen it follow dislocations, ball wounds, and con- 
tusions of nerves, while in an interesting case of Dr. Pack- 
ard’s, it was one of the consequences of compression of 
the sciatic nerve by a tumor. More lately, in the service 
of my friend Dr. J. A. Brinton, at the Philadelphia 
Hospital, I saw a man who had extensive joint lesions, 
owing to the brachial nerves having suffered during the 
dislocation, or upon the subsequent reduction of the hu- 
merus, so that I suspect these troubles are more common 
than has been supposed.! In one case the joints of the 
fingers became swollen and tender on the third day after 
ball wound of the brachial plexus, but usually the swell- 
ing appears much later, and, like the glossy skin, is fre- 
quently the offspring of secondary neuritis. Often masked 
at first by the general inflammation of the limb, or con- 
cealed by the oedema so common after nerve wounds, it 
is more persistent than these, and, as they fade, begins to 
* Rheumatism Visceral, Benj. Ball. Paris, 1866, p. 88. 
| Arch, de Physiol., 1868, p. 160. 
| Dr. Scott Alison (Lancet, March, 1846, p. 278) was the first to de- 
scribe the arthritis of hemiplegia. Although brief, his account of the 
malady is clear and sufficient. 
§ I have since met with similar cases. 170 
INJURIES OF NERVES. 
assume importance. We may then have one articulation— 
and if only one, a large one—involved, or perhaps all the 
joints of a finger, or every joint in the hand, or of the 
entire limb may suffer. The swelling is never very great, 
the redness usually slight, and the tenderness on touch 
or motion exquisite. This condition of things remains 
with little change during weeks or months, and then 
slowly declines, leaving the joints stiff, enlarged, and 
somewhat sensitive, especially as to movement. A small 
proportion of such cases find ready relief, but in many 
of them the resultant anchylosis proves utterly uncon- 
querable, so that it is vain to break up the adhesions 
under ether, or to try to restore mobility by manipulation 
or splints. All alike fail, and serve only to add to the 
essential tortures of the accompanying neuralgia and hy- 
penesthetic states of skin. Since writing my last paper,* 
I have met with some of the former patients who suf- 
fered with these troubles, but in no case originally very 
severe was there any great gain,—indeed in most of them 
the joints had become every year more stiff and useless. 
It is then quite clear that injuries of the spine, diseases 
of this organ, and of the brain, and wounds, or any form 
of lesions of nerves, are capable of developing in the joints 
inflammatory conditions, usually subacute, and which 
so precisely resemble rheumatic arthritis in their symp- 
toms and results, that no clinical skill can discriminate 
between the two. In this state it were well to leave the 
subject. The chemical theories have crumbled, and, in 
the growing tendency to believe that rheumatism may 
have more forms than one, it may not be amiss to recall 
the facts to which we have contributed, and which are 
well illustrated by the following case. Other and more 
severe examples will be found in the cases appended to 
the later chapters of this work. 
* Reports of the Sanitary Commission. REMOTE SYMPTOMS. 
171 
Case 30.— Gunshot wound of the right brachial plexus ; cavs- 
algia; tremor; arthritic lesions; nail-changes; acid sweats; 
hypersesthesia ; little loss of motion from, paralysis ; great gain 
under treatment. B. I). L., aged forty-three, a farmer 
from Maine. Enlisted July, 1862. He was healthy to the 
date of his wound, received July 2d, 1863, at Gettysburg. 
While kneeling and aiming he was shot in the right side 
of the neck. He felt pain in the <vound, but none down 
the arm. Fie spun around, feeling stunned-, and fell on 
his back, not unconscious. In five minutes he arose and 
walked to the rear, where the wound was dressed with 
cold water, no splint being employed either then or later. 
At first, all motion was lost. In an hour he could move 
his fingers and abduct the arm, but not flex it. lie thinks 
sensation was perfect, except as to the ulnar distribution. 
Within an hour he had severe earache, and pain in the 
shoulder, arm, and forearm. During the second week he 
began to have burning pain in the hand. At this time, 
which probably marked the onset of neuritis, the shoul- 
der-joint grew stiff, then the elbow, and lastly all of the 
fingers. This condition was excessively painful, and re- 
mained unchanged. The tremor which is constant in the 
upper arm muscles began the day of the wound, and had 
not ceased on his admission to our wards. 
Site of wound.—On admission, October, 1863, it was 
noted that the ball had entered the right side of the neck, 
in front, three inches above the clavicle, in the outer edge 
of the trapezius. The missile passed downward and out- 
ward, and struck the anterior edge of the supra-spinal 
fossa of the scapula, five inches external to the spine of 
the first dorsal vertebra. Both wounds sloughed, leaving 
scars one and a half inches in diameter. The patient is 
well and florid. The shoulder is motionless from stiffness. 
The lower joints are alike stiff, swollen, red, and painful; 
the arm, semi-prone and flexed, is carried across the chest, 172 
INJURIES OF NERVES. 
supported by the sound hand. • lie has slight motion 
throughout, but the effort causes fibrillar-tremor and ex- 
quisite pain. 
Sensation.—The sense of touch is everywhere good, 
save that there is slight numbness of the back of the hand 
and forearm. Some causalgia is felt in the palm, but no 
other pain, except on movement. 
Nutrition.—The palm is thin and red or purplish, and 
on it the patient uses water, now and then, as a dressing; 
there is no atrophy; the wound is healed, but tender, as 
are also the upper nerve tracks. Muscular hypersesthesia 
of the deltoid and triceps is present. The nails are 
remarkably curved; the hair is scanty; the sweat ill 
smelling and acid. The shoulder muscles alone have lost 
electro-muscular contractility (induction current). Under 
ether, the joints when moved are found to be free from 
well-marked organic adhesions. 
Passive motion and electricity caused speedy gain in 
movement, and in February, 1864, he was able to move 
all the joints with diminished pain. The muscles were, 
at this time, sensitive to induced currents, and the 
numbness and causalgia had nearly disappeared. He 
was allowed a furlough, at the expiration of which he 
deserted. 
This case is valuable as an example of arthritic changes, 
extreme in character, with very little sensory or motor 
paralysis, and seemingly aided by treatment. 
Influence of nerve wounds on secretion.—It has occasionally 
been observed that after nerve injuries productive of neu- 
ritis, and especially in the neuralgic paroxysm, the affected 
parts sweat excessively; but we still need full details as 
to the comparative results in cases of partial and those 
of complete division of a large nerve trunk. As a rule, 
in the few cases of extensive nerve injury which we saw 
at Turner’s Lane Hospital, and where there was evidence REMOTE SYMPTOMS. 
173 
of total loss of function; the skin remained dry, even in 
hot weather; both the oleaginous and sudoriparous glands 
having ceased to act, probably because of atrophic changes. 
In certain instances this was so marked that the region 
involved could be known by the want of moisture. This 
was well seen in wounds of the median nerve. In the 
case of Captain (now Commodore) Stembel, who had 
reflex paralysis of the left arm, with a like but more per- 
manent condition of the right arm and shoulder, there 
was defective sweating of the right limb, with excessive 
secretion in the left; and although some years have 
elapsed, and the right arm has become nearly, and the left 
entirely, well, these symptoms remain unaltered. I saw, 
two years ago, an officer who had no secretion and no 
odor in the left axilla, which was insensible, owing to a 
ball wound of the shoulder. In many of the histories of 
our cases of partial nerve wounds, I find the sweating 
stated to be excessive; but in a number of instances of 
glossy skin, with causalgia, the sweat was not only abun- 
dant, but intensely acid, so that when some of these pa- 
tients passed me in the wards I was aware of their pres- 
ence because of the disagreeable odor, like vinegar, which 
their hands exhaled, despite the constant use of water, to 
which they resorted for relief. In one man the smell was 
disgustingly heavy, and resembled that which comes from 
a bad drain. 
Effect of nerve injuries on calorification.—The examinations 
of temperature made at the Hospital for Nervous Diseases 
were more incomplete than I could have desired, but they 
brought out distinctly one very important difference be- 
tween cases of total section of nerves and those irritative 
lesions which result in causalgia with glossy skin. Since 
then I have studied my cases with great care as to this 
point, and have found that my later conclusions sustain 
those which we then reached. Perhaps a word as to the 174 
INJURIES OF NERVES. 
method of such examinations may not be out of place. At 
our hospital we used the thermometer, held in succession 
on the skin of two parts anatomically symmetrical, and 
which had been subjected for half an hour to the same 
external conditions. More satisfactory results were ob- 
tained by the use of the thermo-electric disks of Becquerel 
and the galvanometer; but of late I have employed a 
small thermometer, the bulb of which is covered on one- 
half of its circumference by a piece of cork, which extends 
a half-inch on either side beyond and also below the bulb. 
By this arrangement the heat is confined, and the time 
needed for the observation is shortened. Some weeks or 
months after complete division of a large nerve, it will be 
found that the affected parts are colder than those which 
are not influenced by the injury. The range in my cases 
was from two to fifteen degrees Fahrenheit lower than 
that of the sound tissues. Mr. Hutchinson’s cases were 
six to ten degrees colder in the parts palsied, and Mr. 
Erichsen had a like result.* 
Where a nerve trunk had been merely injured and not 
thoroughly divided, we commonly found that the tem- 
perature of the affected tissues was lowered in most cases 
from half a degree to two or three degrees ; but when 
there was some irritative lesion, with consequent causal- 
gia and glossy skin, the temperature was either normal, 
or, as happened in the majority of such cases, slightly 
above that of the neiMibomm tissues. 
O O 
At the U. S. A. Hospital for Diseases and Injuries of 
Herves the records were unfortunately only comparative, 
owing to the galvanometer being the instrument used, 
* See, also, Earle, Med.-Chir. Trans., vol. vii. 1816, p. 173, for obser- 
vations on the low temperature of traumatic palsy, and on the effect of 
electricity in raising it Also, Yellowby, same journal, vol. iii. Also, 
W. B. Woodman, in Sydenham Soc. Translation of Wunderlich on Tem- 
perature in Disease, p. 152. REMOTE SYMPTOMS. 
175 
blit they were still sufficiently distinct. I have since seen 
only two cases of glossy skin tissues from nerve wound, 
and in both the temperature of the causalgic region was 
one or two degrees higher than that of the opposite side, 
while above the burning parts the thermometer stood 
usually a degree below that of the healthy limb. This 
slight loss of temperature above the wound is not uncom- 
mon in any nerve lesion, and may be due in part to the 
long and constant disuse of the limb. 
In 1867, Dr. W. W. Keen was kind enough to examine 
for me two of the worst of our former cases of causalgia. 
In both the injured parts were still a fraction of a degree 
warmer than those on the well side. Both of these men 
had improved considerably, and in both the pain had dis- 
appeared. I have been unable to study any case of nerve 
wound immediately after its reception, so that what I have 
here said applies only to dates remote by weeks or months 
from the time at which the wound was received. The 
records of other observers are also deficient in this respect, 
so that we still need a complete thermal study of the heat 
of limbs immediately after nerve wounds, both complete 
and incomplete, as well as a thorough knowledge of the 
influence of irritative lesions and of the remoter changes 
in temperature which time may bring about. We may 
suspect as probable, that within a short period after nerve 
section the temperature rises as it does after physiological 
nerve sections, owing to palsy of the vaso-motor nerves, 
and consequently of the vasal muscle fibres under their 
control. The later loss of temperature which has been 
uniformly observed in these cases is less easy of explana- 
tion. It does not appear to be directly related to the 
state of the sympathetic fibres, because when these alone 
are cut, as in the neck, although the first increase of heat 
is not preserved, the temperature does not fall below the 
normal standard as it does finally after total nerve section 176 
INJURIES OF NERVES. 
in the limbs. As regards these latter, it is likely that the 
utter absence of muscular movement may have some 
influence in causing lowered temperature, but a far larger 
share may be due to atrophic changes in vasal muscles 
and to their subsequent contraction. As the voluntary 
muscles and other parts waste away, the general calibres 
of the greater trunks, both arteries and veins, must be 
diminished, and the circulation lose all of those hastening 
influences which every muscular movement occasions, so 
that in time the general temperature comes at last to be 
distinctly lessened. The slight rise of the thermometer 
which is seen in parts of the body suffering from glossy 
skin and burning, is probably due to localized palsies of 
vessel walls, owing either to direct nutritive changes or 
to reflected impressions, competent to bring about such a 
condition. 
There is a curious and interesting discrepancy between 
the physiological and the clinical results as to the local 
temperatures observed after nerve sections. Bernard has 
shown that section of the anterior or posterior spinal 
nerve roots, or, indeed, of both, does not materially alter 
the temperature of the related tissues, while, on the other 
hand, division of the main nerve of a limb, as the sciatic 
after it has been joined by sympathetic filaments from 
the pelvis, results in considerable elevation of tempera- 
ture in the leg. Schiff believes, however, that portions 
of the vaso-motor nerves pass with the spinal nerve roots, 
and that their division causes slight elevation of the ther- 
mometer, while a higher temperature is to be attained by 
section of the main nerve of the limb. Neither physi- 
ologist has considered the influence of partial section or 
of irritation of nerves. I am aware of no clinical obser- 
vation which records the early rise in temperature after 
total section of the main nerve of a member; but this 
may be due to the fact that the temperature examinations REMOTE SYMPTOMS. 
have been made at more or less remote periods, so that 
it is quite probable that were a case of divided nerve ex- 
amined at all its stages, we should find at first a rise, and, 
after a time, a fall of temperature. Augustus Waller 
has left on record a valuable set of experiments which, 
to some extent, cast light on this subject. He submitted 
the ulnar nerve at the elbow to the influence of a freez- 
ing mixture of ice and salt, or to that of ice alone. At 
first the mercury fell slightly, but so soon as the nerve 
became more completely chilled, and before all sensation 
was absent, the temperature between the third and fourth 
fingers rose several degrees above that of the interspace 
between the first and second digits. When the cold was 
removed and the nerve thawed, the temperature fell, until, 
in the two parts mentioned, it became equal. The phys- 
iological interpretation of these phenomena is a simple 
one. The first influence of cold is to irritate the vaso- 
motor nerve fibres, and thus to occasion a contraction 
of the related blood-vessels and a fall of temperature. 
Whether this be due to a direct influence on these nerves 
or to a centrally reflected impression, is not decided by 
Waller’s observations. As the main nerve becomes frozen 
and ceases to convey messages, the vaso-motors being 
paralyzed, their connected vessels undergo dilatation, 
the temperature rises, and the part flushes, pulsates, and 
feels full. When, in one instance, the ulnar nerve was 
more severely frozen by the use of ice and salt, the tem- 
perature rose as described in the last experiment; but the 
application of the freezing mixture having been too pro- 
longed, there was total loss of motion and sensation, 
which only very slowly grew better, and for some days the 
temperature remained below that of the portions of the 
hand to which are distributed the median and radial 
nerves. In this observation, the physiological conclusions 
as to the later stages of the paralysis were the same as 178 
INJURIES OF NERVES. 
those which obtain in clinical cases of nerve section. As 
if, however, still further to complicate this difficult ques- 
tion, I find, on studying with care the thermal results of 
Waller’s observations on the influence of pressure upon 
nerves, that no matter how complete may be the palsy 
induced by this mechanical cause, it is followed only by 
a fall of temperature in the affected region, and never 
by a rise. This seems to be corroborated by clinical expe- 
rience, since in two instances of arm palsy from sleeping 
on the member, both seen by me within twelve hours of 
the date of injury, there was in one case a fall of one de- 
gree, and in the other of F. There appears to be, 
therefore, some essential difference, as yet inexplicable, 
between the thermal results obtained by freezing and by 
pressure. 
I may add, that I have recently repeated Waller’s ex- 
periments upon my own person, and with results in no 
wise different from his. CHAPTER YIII. 
SENSORY LESIONS. 
Alterations of sensation.—The sensory functions of nerves 
are affected by wounds in such a manner as to be lessened, 
exalted, or perverted, so that we have as results hyperes- 
thesia, anesthesia, and all the varieties of pain, with 
numberless sensations, for the describing of which lan- 
guage fails us, so greatly do they vary with different cases 
of injury. 
Hypersesthesia.—Heightened sensibility, or that state in 
which agents usually felt, as touch only, become painful, 
is sufficiently common after many forms of nerve injury; 
but I cannot recall a case in which it was an immediate 
effect. In some of the older histories of lancet wounds, 
and in many instances of ball wounds, it came on after 
a few days, or later, and was one of the expressions of a 
nerve, the polarity of which had become intensified by 
inflammatory conditions. I have never been able to dis- 
cover that the tactile sense had been thus over-excited, 
so that Weber’s points could be distinguished as two, 
where otherwise they could have been felt but as one. 
When, indeed, there is hypersesthesia for pain, we are 
apt to find it associated with lessened or lost power of 
tactile appreciation, and this rather because of the con- 
fusing influence of pain than necessarily from actual loss 
of tactile appreciation. All cases of glossy skin with 
causalgia were sure to exhibit hypersesthesia of the 
affected surfaces, or of regions near them; and this con- 
dition, in a less intense degree, was likely, after a time, to 
(179) 180 
INJURIES OF NERVES. 
be found elsewhere on the skin, more and more distant 
sensation centres coming by degrees to possess an in- 
creased share of the excitability which at first was con- 
fined to limited groups of ganglia. I recall one very 
striking example of local hypersesthesia, in which the 
ulnar nerve was wounded, so as to cause, in its region of 
ultimate distribution, pain and hyperesthesia. Touch 
did not seem to be lost, but it was certainly enfeebled, 
and even the gentlest contact gave pain. The median 
nerve had been divided, and the contrast as to sensations 
between the skin surfaces to which the two nerves are 
distributed, was both striking and instructive. 
In our book on nerve wounds, a case of hyperaesthesia 
of the thigh is related, in which there was no glossy skin 
or burning pain; and such instances of localized hyper- 
aesthesia in regions remote from the wound may occasion- 
ally be met with. 
I have long suspected that hyperaesthetic states are 
due to several causes. 
In hysteria, the centres are affected, and in many cases 
of causalgia, when the constitutional disturbance is at 
its height, these are so excitable that a touch of the skin 
anywhere, the sound of a step, the rustle of paper, is 
felt to be unpleasant, and even at times exquisitely 
painful. In one case, the right hand having burning 
pain, the left palm became acutely sensitive. In other 
cases, as those due to lancet wounds, the arm and hand 
may become hyperaesthetic very early,—so soon, indeed, 
that we can scarcely escape the belief that something has 
so affected the nerve as to make it produce on the cen- 
tres painful reaction from causes usually incompetent to 
occasion this result. The phenomena which attend upon 
freezing of nerves offer a remarkably instructive illustra- 
tion of the suddenness with which a long line of nerve 
may be brought into such a state as that just described. At SENSORY LESIONS. 
181 
a certain stage of the chilling of the ulnar trunk at the 
elbow, the whole nerve below this point becomes so irri- 
table that the least pressure upon it causes not only pain, 
but sudden motion of every muscle which it supplies. 
In cases of nerve wounds this condition is reached, owing 
to inflammatory states of the nerve; but whether the effect 
be not in every such case merely to heighten the central 
receptive impressibility, we can hardly say. The analogy 
to excited motor states is curious, and, if I may be allowed 
the use of such a phrase, I might describe the general 
hypersesthesia which follows a nerve injury as sensory 
tetan us. 
In cases of causalgia and glossy skin, the hypersesthe- 
sia is due, I think, to nutritive conditions affecting the 
skin surfaces and the nerves beneath them, so as to make 
the latter over-sensitive. The tendency is towards atro- 
phy, and the thinned and shining skin, constantly fretted 
with tiny ulcers, seems at last to fail to shelter sufficiently 
its included nerve ends. Finally, the centres become 
over-sensitive, and radiate their state of sensitive wakeful- 
ness far and wide, just as in tetanus the motor excitability 
floods, at length, the nearer and more distant ganglia. 
Muscular hyperesthesia.—This condition is common in 
gunshot wounds of nerves, and in blows on the back, in- 
juring the outgoing nerves. It was often the sole symptom 
of spinal concussions, and was, in many of them, strictly 
limited to certain muscles. The muscle may be over- 
sensitive when the skin above it is not, and the degree to 
which it is alive to pain where pain should not exist, is 
measured by pressure only. We pinch the skin slightly, 
without giving annoyance, but deep pressure on the mus- 
cles causes soreness, and motion of these parts is nearly 
always productive of more or less pain. 
Defects of sensation; anesthesia.—Defects of feeling may 
exist to any degree after nerve wounds, from the slightest 182 
INJURIES OF NERVES. 
loss of tactile sensibility to the most entire absence of 
that sense, as well as of the feeling of pain and of tem- 
perature. Accurate knowledge as to these losses can 
only he had through careful examination of the skin 
with the aid of certain instruments. 
When examining a patient as to loss of any of the 
sensory functions of the skin, it is, of course, necessary 
to cover his eyes, and, if possible, it is best not to acquaint 
him with the methods about to be employed. We desire 
to learn what change has taken place as to his power to 
discriminate tactile impressions, those of pain, and those 
of temperature. 
As regards touch, we need practically in nerve wounds 
only three tests. For rough examination, the touch of a 
pencil-point on the surface, or, in dubious cases, the tip 
of a feather, suffices to reveal whether the patient feels 
the touch, as he should do; but incessant questioning 
and repeated examinations are sometimes needed, when 
the loss of tactile discrimination is slight. Perhaps the 
most delicate test of all is to touch the tips of single hairs. 
The very slight movement which this produces in the skin 
about the bulb is plainly enough felt during health, but 
a very small diminution in the acuteness of touch will 
cause the motion to be unfelt. By these means we map 
out on the skin the region of affected or lost touch, and I 
have found it convenient, in the hand especially, to record 
these results on previously-prepared drawings of the two 
faces of this part,—a plan which, with slight memoranda 
added, enables me to avoid tedious note-taking. Abso- 
lute annihilation of touch is noted on the diagram by a 
zero within the affected space. 
Having thus made out the region attacked, we wish to 
learn accurately the amount of sensation still left. This 
is far more difficult in local nerve lesions than in central 
anaesthesia, because of the frequent causalgia, hyperaes- SENSORY LESIONS. 
183 
thesias, and cramped positions of the part from muscular 
atrophies and joint-disease. 
For numeral appreciations, we make use of the sesthesi- 
ometer, which consists of a compass the points of which are 
covered with little rounded balls, a scale placed above ena- 
bling us to learn how far apart are the points.* There is 
a more convenient form of instrument, in which the two 
limbs of the compass slide upon a graduated bar. With 
its aid we desire to learn what is the least distance at 
which the separated points can be distinguished as two. 
When nearer than this, they are felt only as one. Weber 
has given very full tables for all parts of the skin, stating 
the distances at which the two points are normally dis- 
tinguished as a single point. Unfortunately, these are 
of limited value in diseased states, because the individual 
sensory capacity varies remarkably, so that it is always 
necessary to compare the part with a corresponding 
portion of healthy skin in order to get a normal stand- 
ard. Even with this aid, the use of the sesthesiometer 
is not so easy or simple as might be supposed. The 
answers often vary when you repeat the observation at 
the same place a few minutes later, and in children or 
unintelligent patients the records thus obtained have but 
little utility. These are intrinsic difficulties which have 
somewhat lessened the practical value of the eesthesiom- 
eter. The precautions requisite to give to its answers all 
possible truthfulness are these: the patient’s eyes should 
be covered, and the part to be examined should be at rest, 
and the compass-points, which ought to be rounded, 
should be lightly placed on the skin, taking care to let 
both come down with equal force and at once, since other- 
wise the succession of impressions informs the patient that 
* Ordinary compasses, and a rule on which to ascertain the extent of 
separation of their parts, answer every purpose. 184 
INJURIES OF NERVES. 
there are two points in use. It is also necessary, in com- 
paring two portions of skin, as that of the forefingers, to 
see that the points lie each time in the same direction, 
since the normal sensibility varies as we test it in the axis 
of a limb, or across it. Above all, it is essential, in every 
examination of sensation, to see that the patient does not 
move the part during the time of testing it. There seems 
to be an almost uncontrollable prompting to do this in 
every instance where the sense of touch is puzzled; and 
if he be allowed to stir the part ever so little, the answer 
he makes will often prove correct, when in the absence of 
motion it would have been defective. The records ob- 
tained by the compass-points may also be written on the 
diagram which is kept for reference, with the notes of the 
case. 
Much more curious illustrations of this tendency to 
aid the touch by movement will be met with when we 
come to examine the power to localize or place a tactile 
sensation. 
It would seem as if, when a patient is aware of having 
been touched, he must be able to say where the touch has 
been. It has been found, however, that when the touch- 
sense is dulled, the person examined is often unable to 
place the sensation correctly. If we touch the finger-tip, 
on being asked regarding it, he is likely to say, You 
touched my knuckle; or if, after touching, he be allowed 
to look at the part, he will indicate the place which he 
supposed touched, and will usually make some gross 
blunder as to its whereabouts. 
There is, regarding this matter, an approach to regu- 
larity. It was stated in our book* that the impression 
was apt to be falsely referred to, or towards some region 
of more distinct sensation. This I have frequently seen 
* P. 116. SENSORY LESIONS. 
185 
illustrated since then, and, although it sometimes happens 
that the impression is not so referred to any very remote 
point, when a mistake is made it is never towards locating 
the touch upon a region of more obscure sensation. 
The error spoken of above as arising from an instinctive 
tendency to move the part examined, is strikingly seen 
in attempts to determine the place of a sensation, so that 
a patient who will mistake one finger for another, if 
these are at rest, will instantly report the matter cor- 
rectly if allowed to move freely the finger examined. 
Now, where we are making continuous pressure on a 
spot, motion of the part may be useful by enabling the 
pressure to be increased or varied, so that the touch is 
rendered more distinct; but when, on the other hand, we 
tap a portion of skin lightly, and the impression so made 
is but momentary, no aid can be had in this direction; yet, 
as I have said, freedom to move the part will secure a cor- 
rect reply in many instances where the sense of tact alone 
has become too dull for this purpose. The explanation 
seems to lie in the fact that the muscles and other parts 
engaged in motion do not sutler always from the defect of 
sensation which has attacked the skin. A touch is felt 
indistinctly upon a finger, for example; we at once move 
the suspected digit, and the sensations which reach the 
brain from its yet sensitive muscles tell us which finger 
has been touched. 
Another fallacy which is apt in careless hands to occur 
when sensation is examined, arises from the lateral propa- 
gation of movement from defective to sensitive regions 
of skin. This can only be avoided by using very gentle 
contacts. 
Finally, in all of these investigations as to the sense of 
tact, it is well to take care that the part studied has on 
any two occasions of examination been subjected to like 
thermal conditions, since a partly palsied hand will give 186 
INJURIES OF NERVES. 
us, when chilled, far different results from those which it 
gave when thoroughly warmed. 
I am well satisfied that in some cases of nerve wounds 
causing atrophic contractions and malpositions, a part of 
the dullness of sensation may be due to the constrained 
postures in which the members have been kept. How 
this sense may suffer from such causes is well illustrated 
by the double sensation which is felt when we examine 
with crossed fingers any round object, as a marble. Parts 
unused to act together are here forced to do so, and in 
consequence we have the sensation of two balls instead 
of one; in other words, we have created what has been 
happily called by Prof. Alexander a tactile squint. In a 
note to the treatise so often referred to, this subject was 
further illustrated by a curious observation which I made 
at that time, and have since repeated. Let the observer 
put his hands behind him, and let them be placed back to 
hack. Then let him interlock his fingers irregularly, 
making the positions unusual, and keeping up mutual 
pressure among the parts so treated. After a few minutes, 
should some one touch lightly one of the fingers, the 
tap will be felt, but now and then the person examined 
will find a difficulty in stating which finger has been 
touched, and he will also discover how strong is the 
instinctive tendency to aid his tact-sense by movement, 
and how readily such movement supplies the required 
information. 
There is but one part of the skin which seems remark- 
ably deficient in power to localize sensations. When, in 
examining the toes, especially in laboring people, we 
touch them in succession, the third toe is sometimes 
mistaken for the fourth, and this for the third; more 
rarely the fourth is mistaken for the fifth, or little toe, 
but this is hardly ever taken for the fourth. My friend 
Dr. J. H. Hutchinson informs me that he has made the SENSORY LESIONS. 
187 
same observation, and I doubt not that this curious fact 
must often have been noticed by others. 
By these various means we learn the boundaries of 
anaesthetic skin spaces as well as the extent of the loss of 
tactile appreciation. 
Pain-sense.—The sense of pain is, of course, readily 
examined by the needle, but where this and tact are so 
far lost as to escape all common tests, the electric brush* 
used on a dry, powdered skin, is the best agent we can 
employ, and if from it no sensation be felt, we may usu- 
ally conclude that the loss of sense is absolute. I can 
recall several occasions where this means has saved me 
from despairing about cases which seemed otherwise totally 
hopeless. 
It is important to hear in mind when examining recent 
cases that sensation may be quite lost for a time from 
shock, and yet return again very rapidly and entirely. 
For these reasons some caution is needed in prognosis. 
When a nerve is wounded, as a rule, motion and sen- 
sation suffer alike; hut it happens in some cases that 
while motion is utterly abolished, sensation is but slightly 
attacked, or does not suffer at all. It is often difficult to 
conceive that the two sets of nerve fibres have not equally 
felt the injury, so that we are obliged to seek for some 
reason why the force which only impairs the sense of 
touch should paralyze the muscle. Perhaps the expla- 
nation may lie in this direction. The nerve centres of 
sensation have an enormous range of appreciation, so 
that even when the transmissive power is weakened, there 
may be still enough to allow of the carriage of a vast 
range of messages to organs possessed of a wide and 
delicate receptivity. On the other hand, the motive im- 
pulse which proceeds from the will must probably reach 
* See chapters on Treatment. 188 
INJURIES OF NERVES. 
the muscle in a definite amount in order to evoke motion, 
and there is reason to think that this amount must be 
comparatively large to get from the muscle a useful 
motor response, or, indeed, any at all. We can thus 
understand that if the motor and sensory filaments be 
equally enfeebled as to transmissive capacity, the brain 
may continue to receive sensory messages, while the 
muscles still fail to get nerve force enough to call them 
into functional activity. Something illustrative of this 
exists normally in the ulnar nerve, which may be easily 
irritated at the elbow so as to cause sensation, but which 
needs much more severe stimulation in order to produce 
movement in the muscles which it controls. 
There may be in other cases an anatomical cause for 
the total escape of one or other set of nerve fibres when 
the injury falls on a nerve trunk where its strands are 
beginning to separate. In some of the lower animals the 
separation of the various nerve filaments into groups, 
some merely sensori-motor, and others either motor or 
sensory alone, is well marked in the parent trunk far above 
the point at which they leave it to seek their points of dis- 
tribution. Now, although the eye does not reveal in 
man any such distinct arrangement of this nature, the 
phenomena of a large number of nerve wounds seem to 
make it probable that very soon after leaving the spine 
the nerves become grouped, as it were, with intention 
towards their final distribution. In no other way can 
we explain some of the phenomena which arise out of 
such cases; but even this resource does not suffice to 
make clear such a case as the following, nor yet others 
which I have seen, where, without obvious cause, a com- 
pound nerve being hurt, motion was lost and sensation 
merely enfeebled or preserved entire.* 
, * In cases of contusion or compression of nerves, the first evidence of 
injury is usually some effect upon sensory filaments, and the mechanical SENSORY LESIONS. 
189 
Case 81*.—Shell wound affecting the musculo-spiral nerve; 
trivial loss of tadilitg; entire motor paralysis in the ultimate 
distribution of this nerve. B. Graham, aged twenty-two, 
enlisted September, 1861, 5th Battery, Massachusetts 
Artillery. He was previously healthy. On May 12, 
1864, he was struck on the back and outside of the right 
arm by a piece of shell, which denuded, but did not break 
the humerus. The wound lay immediately below the del- 
toid insertion, and was five inches wide as it stretched 
across the arm, and three inches in diameter from above 
downward. The arm dropped, and he had sharp pain in 
the wound, so that he cried aloud. The after-pain was 
trifling. As he went to the rear, he examined the limb, 
and found that he could move his fingers a little, but that 
there was no notable loss of feeling. The wround healed 
rapidly, and is now, June 10, 1864, level with the skin. 
Nutrition is unimpaired. The right forearm measures 
nine and three-eighths inches; the left, nine and a half 
inches. 
Sensation.—Outside of the elbow, for a short space, tac- 
tility is enfeebled. In the radial distribution touch is 
slightly less perfect than usual; elsewhere there is no 
lesion of sensation. The supinator longus muscle, sup- 
plied by the musculo-spiral through the branch given oft' 
above the wound, acts pretty well. The extensors of the 
wrist and thumb and the extensor communis are com- 
pletely paralyzed. The interossei act well. The triceps 
extensor is healthy. 
Electric tests.—The muscles above named as paralyzed 
influence may go very far before causing any notable motor indications, 
while as regards spasm, a nerve of double function may be slowly and 
gradually compressed to the utter loss of all function without any such 
muscular convulsion as may at any time originate under sudden varia- 
tions in the amount of pressure. 
* Mitchell, Morehouse, and Keen, op. cit. 190 
INJURIES OF NERVES. 
have no electric contractility, the currents applied to 
them always causing contraction of the flexor group. 
This case well enough illustrates how sensation may 
escape, and motion be largely destroyed. The triceps 
and long supinator were nearly unharmed, while the 
remainder of the extensor group was totally palsied. 
Such was the nature of the wound that it was easy to 
see how the triceps and other brachial muscles escaped 
injury to their nerves. On the other hand, it was very 
difficult to perceive how the muscular branches to the 
forearm could be so completely palsied with such trivial 
injury to the cutaneous and radial branches of tactile 
endowments. 
When sensation is injured, together with motion, the 
former is apt to return first. Thus, for example, a man 
is shot through the arm, so as to partially injure the bun- 
dle of brachial nerves. The first result is entire loss of 
both motion and sensation; but within a day or two the 
latter returns to a great extent, then by degrees certain 
muscles recover their power, and except for inflammatory 
accidents we are in a position, at the close of a week, to 
say how much of the original loss of function is to be 
permanent. Let us again examine this case at the close 
of a year, and we shall find that, counting from this time, 
the gain in sensation is out of proportion greater than 
that of motion. 
In alluding to this fact in our little volume on nerve 
wounds, and while acknowledging the difficulty of fully 
explaining the matter, we sought to account for it in the 
following manner: 
“When a function is partially paralyzed, its continued 
exercise is one of the conditions of its ultimate return to 
full activity so soon as the neural injury has become re- 
paired. How, the sense of touch is in constant automatic 
use, so to speak, every contact being a continuous stimu- SENSORY LESIONS. 
191 
las to its activity, and the very fact of deficient feeling 
subjects the part to rough and unusual irritations. It 
does not seem impossible that this may explain, in part 
at least, the early disappearance of sensory paralysis in 
cases where the function of sensation seems to be quite as 
much affected at the outset as that of motility. 
“ In regard to voluntary movement, the case is quite 
different. When muscles are paralyzed partially, an effort 
of will, and a greater one than common, is demanded to 
call them into action. The early inflammatory conditions 
make motion painful. The effort is unusually wearisome, 
and there is no inevitable and constant stimulus, such as 
exists in regard to touch. Hence, perhaps, it is that mo- 
tility is regained less easily than sensibility, although be- 
yond all this, there are also certain mechanical obstacles 
in the way of a return of voluntary movement, which 
vary greatly, and constitute every single case a special 
object of study. 
“We may sum up the matter in this briefer shape. The 
skin is all the time stimulated, whether we will or not. 
The muscles which volition has ceased to move with ease 
have no such incidental stimulus. Accident and position 
do for the skin what artificial agencies must do for the 
muscles, if we desire to sustain their nutrition and restore 
their power.” 
As the case advances there soon exists a new reason 
for the non-return of motor function in the atrophic 
changes which affect the muscles, and which, after a time, 
place the gravest impediments in the way of movement, 
even though the nerve itself should have become per- 
fectly restored. The receptive centre for sensation remains 
always ready, and incessant stimuli play upon its connected 
sets of nerves. The muscles, on the other hand, the receiv- 
ers of motor impulses, become diseased and unimpressible 
by volition even where at last this is enabled to reach them. 192 
INJURIES OF NERVES. 
Loss of thermal sense.—The sense of temperature is lost 
with that of pain and touch, and usually in like degree, 
and the amount of its loss is, of course, readily measured. 
I have never seen it altered from nerve wounds without 
affection of the pain- and tact-sense. Neither have I met 
with any case of wound of a nerve which seemed to in- 
volve only loss of the muscular sense. 
As concerns the separate existence of nerves of touch 
and pain, some light is cast by two cases—27 and 28—of 
the Report on Nerve Wounds. 
In the first of these, owing to a wound of the arm, 
there was greatly lessened sense of pain, with no loss of 
touch. The patient discriminated the compass-points as 
well in the hand of the wounded side as in the other, 
while, when blindfolded, a large needle could be run 
nearly through the palm without his seeming to feel more 
than a slight pricking. I shall quote this case in full 
when discussing muscular lesions. I do not think it quite 
free from suspicion of central disease,—the result of the 
wound; but, as regards the other case, there cannot be any 
doubt as to the purely peripheral nature of the changes 
which resulted in very remarkable analgesia, with preser- 
vation of the tactile and localizing sensation and that of 
temperature. So complete was the loss of pain-sense that 
the electric wire brush was felt but slightly, while it was 
interesting to note that there was hypersesthesia of the 
deeper tissues. There was total loss of motion below the 
knee. 
Pain.—When we touch or otherwise disturb any part 
of the trunk of a nerve containing sensory filaments, we 
cause, if the irritation be feeble, subjective referred sen- 
sations, such as formication. Warmth or cold so applied 
usually occasions no sense of altered temperature in the 
skin, but only pain in the ultimate neural distribution. 
More severe mechanical disturbance, at any part of a SENSORY LESIONS. 
193 
nerve, is felt as pain, and into this sad language the nerve 
finally translates all save the mildest impressions made 
elsewhere than upon its peripheral expansions. 
In many cases, the nervi nervorum enable us to local- 
ize the point at which the nerve is injured, as when a 
blow falls on the ulnar nerve at the elbow. We feel in- 
tensely the referred pain, hut have also a clear sense of 
local hurt to the nerve at the point struck. This is, how- 
ever, by no means usual as to causes which act slowly 
and steadily. So that when in disease wTe feel pain, it is 
often impossible to say at what point of the nerve track 
the pain-making cause is busy, nor how remote it is from 
the region where the pain seems to be. 
Any mechanical or other irritation of a nerve of com- 
mon sensation is usually referred to its region of periph- 
eral distribution, so that the pain appears to exist in that 
part. 
Nerve injuries may also cause pain which, owing to 
inexplicable reflex transfers in the centres, may be felt in 
remote tissues outside of the region which is tributary to 
the wounded nerve. 
When the later pathological changes of an irritative 
nature which follow nerve injuries begin to occur, new 
causes of pain arise, the reflex references become wider, 
and when in certain eases the nutrition of the skin sutlers, 
novel forms of suffering spring up, which are due to 
alterations of the peripheral nerve ends or their protective 
tissues. 
Pain is, perhaps, the most constant sequence of nerve 
injuries, but it exhibits the utmost variety as to the time 
of its coming and the character of the torment. I have 
already discussed the question of pain as regards the first 
moments of nerve wounds. In cases of contusion, the 
first pain having passed, only tingling may remain, unless 
secondary changes in the nerve result in the production 194 
INJURIES OF NERVES. 
of the pains of neuritis. In many punctured wounds, the 
whole nerve seems to be thrown suddenly into an hyper- 
aesthetic state, so that it continues to express irritation in 
the shape of very agonizing pain. After a time, such a 
nerve becomes congested or inflamed, and hyperplasia of 
inter-neural connective tissue occurs, the pain still con- 
tinuing or growing worse. 
In cases of simple equal pressure on nerves, pain may 
not be a prominent symptom, but will be most apt to be 
felt severely when the pressure is varying from time to 
time. Pressure, with inflammatory or cancerous altera- 
tions, is the parent of most horrible forms of anguish, such 
as we see so often in cancer, affecting the pelvic and sacral 
plexuses. 
In gunshot injuries of nerve trunks, pain may be con- 
tinuous from the outset, but more commonly the neural- 
gias date from the time of the traumatic fevers, or even 
still later. 
Early in this chapter I drew a distinction as to the 
three methods in which nerve pains originate, and it is 
again necessary here to return to the subject. In a 
large number of cases, and in most of the pains of in- 
flamed or scleromie nerves, the pain comes from irritation 
of fibres in or near the wound, the nerve tubes or the 
centres becoming hyperresthetic and the sensation being 
referred to the peripheral tissues. But in many instances 
like pains arise, although the nerve be cut across, or the 
member lost, as in stump neuralgias, there being still 
the same reference of the pain to a supposed seat. The 
important difference between these two conditions, both 
fertile in torment, lies in the fact that when portions 
of the fibres of a nerve are still uninjured, but irritated, 
certain nutritive mischief may be made in the peripheral 
parts, and we may thus have evolved a peculiar type of 
anguish, the remote cause of which is in the wound, the SENSORY LESIONS. 
195 
immediate cause in the region of ultimate nerve supply. 
In this manner are produced, as I believe, the horrible 
pains of causalgia. 
The neuralgias common to all nerve injuries, and 
which I desire clearly to distinguish from causalgia, with 
which I should add they may coexist, are apt to affect a 
quotidian type, and to occupy, as a rule, the latter rather 
than the earlier hours of the day. It is curious, and as 
yet unnoticed, that the pain of non-malarial neuralgia 
and of neuritis and neural sclerosis never assumes a 
tertian or any other than a quotidian type. It is quite 
rare for a patient to arouse frem sleep with pain, and I 
have heard men remark that it took some time to get 
awake to the pain. This is familiarly illustrated where 
the toothache of the last night does not come on next 
day until exercise has stimulated the circulation. The 
tendency to intermit or remit in ordinary neuralgias fre- 
quently causes them to be ascribed to malaria; but the 
same tendency is seen in traumatic cases, or in the pains 
caused by pressure on nerves, as from aneurism, but is 
much more rare in those which I class as causalgia, 
and in which the pain usually appears at the time the 
man awakens and pursues him with increasing torture 
throughout the day. 
Mr. Swan relates some curious instances of traumatic 
pain of an intermittent type. In one, an ulcer over the 
peroneal nerve occasioned a pain which recurred daily at 
the same hour, and I have myself seen numerous in- 
stances of pain from direct injury where this condition 
was met with. Usually the pains from nerve hurts are 
either aching, shooting, or burning, or perhaps all three 
at once Looking carefully through my notes as to this 
point, I find that in a considerable proportion of gunshot 
wounds of nerves there is principally burning pain, or at 
least that this is the prominent symptom, while in slight 196 
INJURIES OF NERVES. 
injuries of nerves from compression or contusions, the 
other forms of pain are more apt to prevail. 
Perhaps few persons who are not physicians can realize 
the influence which long-continued and unendurable pain 
may have upon both body and mind. The older books 
are full of cases in which, after lancet wounds, the most 
terrible pain and local spasms resulted. When these had 
lasted for days or weeks, the whole surface became 
hypersesthetic, and the senses grew to be only avenues 
for fresh and increasing tortures, until every vibration, 
every change of light, and even, as in Miss Willson’s case,* 
the effort to read brought on new agony. Under such 
torments the temper changes, the most amiable grow 
irritable, the soldier becomes a coward, and the strongest 
man is scarcely less nervous than the most hysterical girl. 
Perhaps nothing can better illustrate the extent to which 
these statements may be true than the cases of burning 
pain, or, as I prefer to term it, causalgia, the most terri- 
ble of all the tortures which a nerve wound may inflict. 
In delineating this form of pain, perhaps I cannot do 
better than transfer to these pages the account originally 
written while I was seeing almost daily numbers of 
persons suffering as I have described them : 
“In our early experience of nerve wounds, we met with 
a small number of men who were suffering from a pain 
which they described as a ‘burning,’ or as ‘ mustard red- 
hot,’ or as a ‘ red-hot file rasping the skin.’ In all of these 
patients, and in many later cases, this pain was an asso- 
ciate of the glossy skin previously described. In fact, 
this state of skin never existed without burning pain. 
Recently we have seen numbers of men who had burning 
pain without glossy skin, and in some we have seen this 
latter condition commencing. The burning comes first, 
* Swan, op. cit. 197 
SENSORY LESIONS. 
the visible skin-change afterwards; but in no case of 
great depravity in the nutrient condition of the skin have 
we failed to meet with it, and that in its forms of almost 
unendurable anguish. 
“We have some doubt as to whether this form of pain 
ever originates at the moment of the wounding; but we 
have been so informed as regards two or three cases. 
Certain it is that, as a rule, the burning arises later, but 
almost always during the healing of the wound. Of the 
special cause which provokes it, we know nothing, except 
that it has sometimes followed the transfer of pathologi- 
cal changes from a wounded nerve to unwounded nerves, 
and has then been felt in their distribution, so that we do 
not need a direct wound to bring it about. The seat of 
burning pain is very various; but it never attacks the 
trunk, rarely the arm or thigh, and not often the forearm 
or leg. Its favorite site is the foot or hand. In these 
parts it is to be found most ofteu where the nutritive skin- 
changes are met with ; that is to say, on the palm of the 
hand, or palmar face of the lingers, and on the dorsum of 
the foot: scarcely ever on the sole of the foot, or the back 
of the hand. When it first existed in the whole foot or 
hand, it always remained last in the parts above referred 
to, as its favorite seats. The great mass of sufferers de- 
scribed this pain as superficial, but others said it was also 
in the joints, and deep in the palm. If it lasted long it 
was finally referred to the skin alone. 
“Its intensity varies from the most trivial burning to a 
state of torture, which can hardly be credited, but which 
reacts on the whole economy, until the general health is 
seriously affected. The part itself is not alone subject to 
an intense burning sensation, but becomes exquisitely 
hypersesthetic, so that a touch or a tap of the finger in- 
creases the pain. Exposure to the air is avoided by the 
patient with a care which seems absurd, and most of the 198 
INJURIES OF NERVES'. 
bad cases keep the hand constantly wet, finding relief in 
the moisture rather than in the coolness of the applica- 
tion. Two of these sufferers carried a bottle of water 
and a sponge, and never permitted the part to become dry 
for a moment. As the pain increases, the general sym- 
pathy becomes more marked. The temper changes and 
grows irritable, the face becomes anxious, and has a look 
of weariness and suffering. The sleep is restless, and the 
constitutional condition, reacting on the wounded limb, 
exasperates the bypersesthetic state, so that the rattling of 
a newspaper, a breath of air, the step of another across the 
ward, the vibrations caused by a military band, or the 
shock of the feet in walking, gives rise to increase of pain. 
At last the patient grows hysterical, if we may use the 
only term which describes the facts. He walks carefully, 
carries the limb with the sound hand, is tremulous, nerv- 
ous, and has all kinds of expedients for lessening his pain. 
In two cases, at least, the skin of the entire body became 
hypenestlietic when dry, and the men found some ease 
from pouring water into their boots. They said, when 
questioned, that it made walking hurt less; but how, or 
Why, unless by diminishing vibration, we cannot explain. 
One of these men went so far as to wet the sound hand 
when he was obliged to touch the other, and insisted that 
the observer should also wet his hand before touching 
him, complaining that dry touch always exasperated his 
pain. Cold weather usually eased these pains; heat, and 
the hanging down of the limb, made them worse. Motion 
of the part was unendurable in some of the very worst 
cases; but, for the most part, it did no harm, unless so 
excessive as to flush the injured region. 
“ The rationale of the production of this form of pain 
was at first sought for among reflex phenomena. It then 
seemed to us probable that a traumatic irritation existing 
in some part of a nerve trunk was simply referred by the SENSORY LESIONS. 
199 
mind to the extreme distribution of this nerve, agreeably 
to the well-known law of the reference of sensations. 
“Further study led us to suspect that the irritation of 
a nerve, at the point of wound, might give rise to changes 
in the circulation and nutrition of parts in its distribution, 
and that these alterations might be themselves of a pain- 
producing nature. The following considerations tend to 
strengthen the view, that the immediate cause of burning 
pain lies in the part where the burning is felt: 
“If the burning were a referred sensation, it would 
sometimes be met with in cases of complete division of 
nerves, and, therefore, in parts devoid of tactile sensation. 
But we have encountered no such cases; and, on the 
other hand, the burning pain is often accompanied with 
hyperesthesia, while motion and touch may remain unal- 
tered. Is it not probable that the depraved nutrition, 
often so marked in the congested, denuded, and altered 
skin, may give rise to a disease of the ultimate fibres of 
the sensitive nerves? Just such a pain comes when we 
attack the cutis with irritants; and let us add, that the 
agents which help these cases of burning are those ad- 
dressed to the spot where the pain is felt, and not to the 
cicatrix.” 
Since this description was written, several years have 
gone by, but new experience has only strengthened my 
belief that the explanation just given is physiologically 
correct, because in a large number of amputated cases— 
many of them neuralgic—I have never yet seen a case 
of subjective burning pain. I add two cases of causalgia 
from my notes, whilst under the head of Illustrations of 
Treatment the reader will find other and more severe 
examples. 
Case 32.—Leg wound; causalgia; slight sensory and no 
motor defects; crutch palsy ; cure in four months. Christo- 
pher Beatty, aged twenty-four, carpenter, Pennsylvania, 200 
INJURIES OF NERVES. 
sergeant 26th Pennsylvania Volunteers, was shot at Chan- 
cellorsville, through the leg, below the knee. lie fell 
without pain ; lost blood largely; and, after lying on the 
field twenty-six hours, had a water-dressing applied, at 
about which time the heel began to burn. A few days 
later, the limb being swollen considerably, the whole foot 
was burning and prickling intensely,—the sole being the 
worst part. After two weeks the prickling lessened, but 
the burning remained. 
He was wounded in May, 1863, and admitted to the 
IT. S. A. Hospital for Nervous Diseases, June 30, 1863, 
when he had no loss of motion, and scarcely any of sen- 
sation, only the great-toe and heel being not quite up to 
the normal standard of sensibility. The heel and the 
inner edge of the plantar arch burn intensely, and are 
dark-red and mottled, and swollen from congestion, which 
the dependent position greatly increases. Pressure upon 
the cicatrix appears to increase the burning. He had, 
soon after admission, crutch palsy, which readily yielded 
to treatment. The burning pain slowly lessened without 
any therapeutic aid, and within four months of the date 
of the wounding he was well, excepting some tenderness 
and slight oedema of the foot. 
In the following case there were both burning pain and 
common neuralgic pain, and the mental condition pro- 
duced by intense suffering was well marked : 
Case 33.— Wound of right arm; glossy skin; causalgia 
and neuralgia ; joint disease ; acid sweats ; slight loss of tact; 
constitutional symptoms. II., aged thirty-nine, New York, 
was shot July 2, 1863, through the inner edge of the 
right biceps, half an inch above the internal condyle of 
the humerus; the ball passed backward and downward. 
The musket fell from his left hand, and the right, grasp- 
ing the rod, was twisted towards the chest and bent at the 
elbow. He walked to the rear. He cannot tell how much SENSORY LESIONS. 
201 
motion was lost, but he knows that he had instant pain in 
the median distribution, with tenderness of the palm, 
even on the first day, and a sense of numbness. My 
notes describe him on entering our wards as presenting 
the following symptoms: the temperature of the two 
palms is alike. The back of the hand looks as usual, but 
the skin of the palm is delicate and thin, and without any 
eruption. The joints of the fingers are swollen, and the 
hand secretes freely a sour, ill-smelling sweat. The pain 
is, in the first place, neuralgic, and darting down the 
median nerve track into the fingers ; while, in the second 
place, there is burning in the palm and up the anterior 
face of the fingers. 
Pressure on the cicatrix gave no pain, but the median 
nerve below that point was tender, and pressure upon it 
caused pain in the hand. There was slight want of tactile 
sensibility in the median distribution in the hand, but 
the parts receiving the ulnar nerve presented no sign of 
injury. The hj’peraesthesia of the palm was excessive, 
so that even to blow on it seemed to give pain. He kept 
it wrapped up and wet, but could not endure to pour 
water on to the palm, preferring to wet the dorsum of 
the hand and allow the fluid to run around, so as by 
degrees to soak the palm. After a few weeks of this tor- 
ment he became so sensitive that the rustle of a paper or 
of a woman’s dress, the sound of feet, the noise of a band, 
all appeared to increase his pain. Ilis countenance at 
this time was worn, pinched, and anaemic, his temper 
irritable, and his manner so odd that some of the attend- 
ants believed him insane. When questioned as to his 
condition he assured me that every strong moral emotion 
made him worse,—anger or disappointment expressing 
themselves cruelly in the aching limb. There was also 
the most marked liyperaesthesia of the skin throughout 202 
INJURIES OF NERVES. 
the bod}T, so that a sudden touch anywhere was unpleasing, 
and reacted on the diseased hand. 
It would be easy to add numerous instances of causalgia 
and neuralgia from nerve wounds, but as I shall have to 
relate cases, perhaps to a tedious extent, in illustrating 
diagnosis and treatment, I shall cite no more at this time. 
Effects of nerve injuries upon the function of muscles.— 
Mechanical disturbances of nerves give rise to the various 
forms of spasm and tremor, and to paralysis of motion, 
and consequent atrophic changes and contractions. 
Local spasm.—I have already described the sudden and 
violent form of spasm which is sometimes the first symp- 
tom of the wound of a nerve by a ball, and I have also 
called attention to the painful spasms which may result 
almost instantly from the wounding, and probably even 
from the division, of a small sensitive skin nerve in bleed- 
ing at the elbow. The latter variety of spasm may last for 
days, and even for weeks, until, as in one instance, the 
growing nails of the clinched hand may cause ulcers in 
the wounded palm. In these cases, as in wounds from mis- 
siles of war, the spasms are of reflex origin, and are often 
seen in the muscles of unwounded nerves. In the case 
of J. II. C.,—related in our Report on Nerve Wounds,— 
the bullet injured the left median and ulnar nerves, and 
caused instant cramp of the flexors of both arms, so that 
he clutched both gun and ramrod violently. He shook 
loose the latter with a strong effort, and then, with the 
right hand thus set free, he unlocked the fingers of the 
left from their clutch on the gun, after which they did 
not again close. 
Tonic contractions of muscles are occasionally met with 
at a later stage of these injuries, but are, perhaps, among 
the rarest of the secondary symptoms. Such forms of 
spasm are readily diagnosticated from atrophic shortening, 
by the fact that muscles affected with the latter malady MUSCULAR LESIONS. 
are unexcitable, as a rule, by induced electric currents, 
whilst muscles in a state of spasm are often abnormally 
irritable under this form of stimulation. The atrophied 
muscle is hard, shrunken, and motionless, and cannot be 
elongated. The muscle in spasm is firm, plump, often 
exhibits fibrillar movement, and can be lengthened when 
the patient has been made insensible by ether or chloro- 
form. When awake, the effort to extend these muscles 
causes pain and increasing spasmodic contractions. We 
remarked in our wards* many cases of what might be 
called a tendency to spasm, which was shown by quiver- 
ing and resistance in a muscle, which gave no proof of 
spasm until suddenly extended by the hand of the physi- 
cian or by the action of its antagonists. In a case of injury 
of the shoulder, which I saw a year ago, the lower arm 
nerves became secondarily diseased; and, owing to this, 
the supinator longus and biceps passed into the condition 
described. The arm was carried slightly bent, but if I 
extended it, a spastic contraction of these muscles drew 
it into a state of extreme flexion, which lasted for some 
minutes, during which the fibres of the muscle could be 
felt to be firmly contracted. 
I was lately consulted by Dr. Ellis, of Elkton, Maryland, 
in regard to a patient who presented a remarkable instance 
Of this form of fibrillar spasm. 
The lad, aged eighteen years, was run over five years 
previously by a cart, which passed across the back of the 
neck and the right shoulder. Both arms were palsied 
as to motion alone. The left recovered entirely, as did 
also the right forearm and hands; but the arm muscles, 
except the triceps extensor, remained motionless, and 
became excessively wasted. The atrophied deltoid, supra- 
and infra-spinatus, and biceps are now the seats of the 
* Gunshot Injuries of Nerves, op. cit., p. 124. 204 
INJURIES OF NERVES. 
most constant and curious quivering, while, strangely 
enough, every one of them is perfectly responsive to in- 
duced currents. The first electric application at once 
restored partial volitional control, and he is,now rapidly 
improving. 
The following case is a good illustration of tonic spasm : 
Case 34.—Shell bruise of right brachial nerves ; slight loss of 
motion ; ionic spasm of the flexor carpi radialis, flexor carpi 
ulnaris, and palmaris longus, causing violent flexion of wrist; 
analgesia well marked; no loss of tactilitg ; sections of tendons ; 
relief. Lawrence Monaghan, aged twenty-six, machinist, 
Kentucky, enlisted January, 1863, and had been previ- 
ously in the nine months’ service. At Chancellorsville, 
May 3, 1863, he was struck by a fragment of shell on the 
outside of the right arm, seven inches above the external 
condyle. It merely scratched the skin, but bruised the 
subjacent parts severely and extensively. When hit, he 
was lying down, leaning on the left elbow, lie felt 
nauseated; the arm dropped with general weakness and 
numbness, and with slightly impaired sensation. The 
wound swelled and grew black and red, being bruised 
from the shoulder to the middle forearm. 
At first the pain limited movement, but in two months 
the motions of the arm were much better throughout. 
Sensation also improved, but was'never quite perfect. 
About the second week, and while the arm was in a 
sling, on a pad, the wrist began to flex. The surgeon’s 
attention being called to it, he put it on a splint and 
bandaged it down ; but after four weeks this treatment 
was abandoned on account of the pain, and also because 
it proved useless. After this, liniments to the arm were 
used, but the flexion went on. Then, as the arm grew 
stronger, the contraction relaxed ; and, finally, he was 
mustered out of service. Re-enlisted August 15th, Com- 
pany A, 10th New Jersey Volunteers. MUSCULAR LESIONS. 
205 
The handling of a musket brought back the pain, 
which was a numb aching, extending to the hand. At 
the same time the wrist began to flex anew, and forcibly, 
with pain also in the wrist and in the track of the mus- 
culo-spiral nerve; the hand being constantly cold, and 
kept covered with a glove. 
March 9, 1864, admitted.to Turner’s Lane Hospital.— 
Nutrition good; skin natural, but soft and moist, from 
being covered and unused. Acid odor distinctly marked. 
Examined by compass, no perceptible difference in tac- 
tile sensation from the other hand. He feels the cold in 
his right hand severely; it becomes cold easily. lie has 
every movement; but the finger flexion is limited by 
the extreme bend of the wrist, for when in this condi- 
tion, the two flexors of the Angers cannot shorten enough 
to flex the second and third digital joints. Of course 
voluntary extension of the wrist is impossible, but he lias 
perfect extension of all the digital joints. The flexor carpi 
radialis, the palmaris longus, and flexor carpi ulnaris are 
very rigid', and when extended, contract violently. 
These muscles appear to possess fully as much electric 
contractility as those of the other arm. 
June 12.—Hr. Keen cut the tendons of the flexor carpi 
radialis and palmaris longus completely, and that of the 
flexor carpi ulnaris partially. The wrist was then brought 
to a right line with the forearm, and placed on a Bond’s 
splint. Motion soon began to return to the fingers as 
the soreness arising from change of position subsided. 
The patient is now, July 1st, recovering rapidly. 
Muscular paralysis and its consequences.—Loss of power 
is of course the most common result of nerve wounds, 
and may exist in every possible degree, from the slightest 
defect to the most absolute annihilation of the motor func- 
tion of an entire limb. The consequences which follow, in 
the shape of atrophy and contractions, I have already de- 206 
INJURIES OF NERVES. 
scribed, but the practical difficulties as to treatment which 
they occasion we have yet to consider. 
It is very fortunate that not every muscle palsied by 
nerve injury undergoes great atrophy, and that of those 
which endure this change, not alj are affected by conse- 
quent shortening. The force with which organic short- 
ening of muscles acts is most remarkable, and is some- 
times so great as to cause dislocations and to produce the 
most horrible deformities, since the healthy opponent 
muscles are powerless to resist the steady contraction 
caused by morbid conditions. The most curious in- 
stances of this are to be found in what is known as the 
claw-hand, which is due to paralysis of the interossei of 
the hand, and organic shortening of the flexors of the 
fingers, the extensor communis remaining intact. (For 
examples of this condition, see cases at the close of this 
chapter.) The same evils result more frequently, but in 
less mischievous forms, from complete palsy of muscles, 
which undergo no further changes, but the complete re- 
laxation of which enables their opponent groups to distort 
the part by slow degrees. Almost every case of nerve 
wound offers illustrations of this, which, like every form 
of unopposed contraction, is fertile in lasting evil when 
it exists in connection with arthritic troubles; for when 
this is the case, the displacements made by the muscles 
are rendered, as it were, permanent by the adhesions 
which fix the joints in their abnormal positions. 
When describing the practical annoyances in treatment 
which arose out of -these conditions, we* called attention 
to the loss of motion which results from a part being 
held in an extreme of flexion, as in the case of Monaghan, 
page 204. Here the hand was so bent upon the wrist that 
the second and third phalanges could not be completely 
* Gunshot Wounds, etc., p. 122. ILLUSTRATIVE CASES. 
207 
flexed, partly, as I suppose, because of the excessive 
shortening needed by the flexors to enable them to act 
upon their relaxed tendons, and partly because of the 
extreme tension which the extensor communis exerted 
upon the first phalanges. I saw, a few months since, a 
case in which, owing to various causes, the hand was 
fixed in extreme extension. The patient was powerless 
to effect full extension of the fingers. It is easy to make 
this experiment upon one’s self, and thus to learn the 
limitation of movements brought about by placing a 
part in excessive degrees of flexion or extension. 
The cases which follow are selected from notes taken 
by Dr. Keen and myself, because each of them con- 
spicuously illustrates some one or more of the conse- 
quences of nerve wounds. 
Case 35. — Gunshot wound of left forearm ; median and 
ulnar nerves involved; paralysis of motion; none of sensation; 
rigid fingers from joint disease ; neuritis and causalgia from 
tenth day; relief by blisters; eruptions above the limit of cau- 
salgia; red palm. J. D., aged twenty-three, carter, Ireland; 
enlisted August, 1861, Company F, 69th Pennsylvania 
Volunteers. His health was good until he was wounded. 
While firing, he was shot in the left forearm, behind the 
ulna, four and a half inches below the olecranon process. 
The wound of exit was three inches above the internal 
condyle of the humerus, and half an inch in front of it. 
Heither artery nor bone was injured. He fell uncon- 
scious, but in half an hour, reviving, arose, and, walking a 
few steps, fell again. At the expiration of three hours, 
a water-dressing was applied. JSTo other dressing was at 
any time employed. Motion below the elbow was totally 
lost. As to sensation at this time, the evidence is uncertain. 
He was removed to West Philadelphia Hospital, where 
the water-dressing was continued. The arm was put on 
splint, and passive motion of the fingers made daily. On 208 
INJURIES OF NERVES. 
the tenth day he had fever and rigors, with darting pains 
in the wound. The nerves became tender on pressure, 
and intense burning pain, beginning on the front of the 
wrist, extended to the palm and the face of the index- 
tinger alone. 
Six months later, when admitted to Turner’s Lane 
Hospital, he is described as thin, anaemic, nervous, and 
pain-worn ; sleeps badly, and has ague and dyspepsia. The 
arm is generally wasted; he keeps the hand wet. Eczema 
of forearm above the line of pain is present. There is no 
swelling; the odor of the hand is almost fetid. The left 
biceps measures seven and a half inches; the right, eight 
and one-eiglith. The left forearm measures eight inches; 
the right, nine inches. The hand is flexed on the wrist 
from contraction of the flexors; the nails are much 
curved. The median nerve is exquisitely sensitive to 
pressure in the forearm, the ulnar only at the wrist. Mo- 
tion is entire above elbow and at the elbow, save that ex- 
tension is incomplete, from stiffening of the joint. Pro- 
nation and supination are almost lost from joint-troubles. 
The hand flexors retain a fair amount of power. There 
is no power to extend the hand above the level of the 
wrist. The thumb can be passively moved, but there is 
no voluntary control over the metacarpal joint move- 
ments, although the last phalanx can be extended or 
flexed. The fingers are very rigid,—their joints swollen. 
They can be slightly stirred by will in abduction, adduc- 
tion, flexion, and extension perhaps to one-third their 
usual extent. The movements were more limited by the 
state of the joints than by muscular palsy, because, except 
the supinator longus and the thumb muscles, the other 
muscles respond readily to induction currents. Under 
cod liver oil, quinine, ale, and good diet, the patient 
speedily improved, and after a month was treated for the 
causalgia by blisters, made at first with liq. ammonise ILLUSTRATIVE CASES. 
209 
fort., and then with cantharides. Six blisters etfected a 
cure of the pain, and when he left us, after three months, 
his state was altogether satisfactory save as to the rigid 
joints, which, although improved by passive movement 
and the cold douche, were by no means well. The 
paralysis remained unaltered. 
Case 36.—Bruise of left ankle ; loss of motion in foot; no 
loss of sensation; local subcutaneous effusions of blood; electrical 
treatment; cure. A. J. M., aged thirty, enlisted August, 
1862, Company Iv, 13th Pennsylvania Cavalry. Except 
that he was liable to muscular rheumatism, he was healthy 
until hurt. On February 16, 1863, his horse fell with 
him, and pinned his left foot between the saddle and 
the ground. The foot was much bruised, but could be 
moved with pain until the fifth week, when he lost power. 
At this time, also, he had slight darting pains about the 
knee and thigh, and the foot became cold, although to him 
it felt hot. April 18,1864, when I first saw him, the sciatic 
nerve was tender, and its diverging branches still more 
so. The foot was hot and flushed, and could not be vol- 
untarily moved, either in flexion or extension, while the 
calf muscles and the anterior leg groups were only slightly 
excitable by the most powerful induced currents. There 
was very little pain. The foot and ankle were generally 
red, with here and there spots of more marked conges- 
tion. The instep and sides of the foot and ankle were 
dotted with large and small spots, some like bruise-marks, 
and others more defined, and resembling purpura. 
Under the use of induced currents the man was rapidly 
cured. Alternate cold and hot douches constituted the 
only additional treatment. At the close of six weeks he 
had had twenty applications of the battery, and had nearly 
entirely recovered all the lost movements. The foot was 
cooler and the eruption gone. 
Case 37.— Wound of median and ulnar nerves ; atrophy and 210 
INJURIES OF NERVES. 
contraction of flexor muscles ; atrophy of all the hand muscles ; 
neuro-iraumatic arthritis ; loss of sensation ; moderate improve- 
ment; discharge. G. L./aged thirty-one, lumberman ; en- 
listed, May, 1861, Company C, 1st Minnesota Infantry. 
He was healthy to the date of the wound, which was 
received July 3,1863. While advancing at a walk and 
capping his gun, a ball entered the right biceps three and 
a quarter inches above the level of the internal condyle, 
and made its exit three and a quarter inches directly below 
the same condyle, wounding the main artery and the ulnar 
and median nerves. The hand and forearm flexed spas- 
modically, and the man, tying a handkerchief around the 
arm to check the flow of blood, walked to the rear, suf- 
fering with some pain down the front of the arm, but not 
in the hand. Motion and feeling were both absent. Three 
hours later the artery was tied. A cerate dressing was 
applied, and no splint was at any time used. The wound 
healed in two months, and at this time sensation and mo- 
tion began to improve. He was admitted to T-trmor’s 
llospital, December 24, 1863, when his case was 
thus described: the right hand is congested and a little 
swollen. In the flexor carpi radialis the loss from atrophy 
is one-half. In the other flexors, supinators, and pronators 
the loss is one-tliird. In the thumb muscles proper and 
abductor minimi digiti it is one-fourth. 
The deep and superficial flexors and the thumb muscles 
are slightly contracted. Up to the third month the fingers 
were straight, but about that time they began to bend, and 
on admission were semi-flexed. 
The biceps acts very little; the supinator longus, al- 
though enfeebled, being competent to flex the forearm. 
Extension is incomplete from partial contraction of the 
biceps, owing to the prolonged flexion of the arm ; pro- 
nation is incomplete, but the supinating power is fentire. 
The hand can be raised only to the arm-level, when the ILLUSTRATIVE CASES. 
211 
contractions of muscles and the state of the wrist-joint 
check it. The thumb has one-third flexion and extension, 
owing to want of power. 
The first joints of the fingers are in good order; the 
second a little swollen and stiff; the third joints are rigid, 
enlarged, and painful, especially in the index-finger. The 
first joints have pretty fair mobility; the second but little; 
the third none at all. As the fingers are semi-flexed, the 
will can still act on the first phalanges, and slightly on the 
second, but the third rest bent and motionless. The same 
statement may be made as to the power to voluntarily ex- 
tend them. The contracted state of the common flexors 
has now lessened, but the joint inflammations, which arose 
early in the case, have fixed the fingers in the vicious 
positions into which they were drawn by the muscular 
shortening. 
Touch is good in the arm; absent in the palm and 
palmar face of the fingers, except as to the thenar emi- 
nence. It is good on the dorsum of the hand, but de- 
fective on the back of the last phalanx of the first finger, 
the second and third phalanges of the second and third 
fingers, and on the metacarpal bone of the fourth finger. 
Electro-muscular contractility is lessened in the supi- 
nator longus; absent in the common flexors, although 
these have some voluntary power; nearly absent in the 
thumb muscles, the muscles of the fourth finger, and 
interosseal groups. 
The marked feature of this case was the obstinate and 
painful inflammation, and stiffness of the third joints of 
the fingers and of the articulation of the wrist; yet these 
conditions were nearly entirely relieved by three months 
of passive motion, electrization by induced currents, and 
the dry wire brush, douches, and attention to the general 
health. 
Case 38.— Wound of left chest, causing paralysis of the 212 
INJURIES OF NERVES. 
great 'pectoral muscle, probably by injury to the external anterior 
thoracic nerve ; extension of disease from the wounded nerve to 
the brachial plexus, with consequent loss of sensation and mo- 
tion ; lesions of nutrition ; intense burning pains; musculo-spiral 
and median principally affected. Stephen Warner, aged 
thirty-three, farmer, New York, enlisted August, 1862, 
Company B, 18th Pennsylvania Volunteers. lie was 
healthy to date of receipt of wound. At Locust Grove, 
November 27, 1863, a ball entered the left chest, under 
the first rib, half an inch below the clavicle and two and 
a half inches from its sternal end. Passing probably under 
the arch of the subclavian artery, it went backward and 
downward, and made its escape two inches below the infe- 
rior angle of the left scapula, three and a quarter inches 
from the spine. The ball was fired b}T a skirmisher not 
twenty yards distant, and was received while the patient 
was in the act of bending forward to aim. lie'fell, giddy, 
but conscious; tried to move, but failed, and fainted from 
loss of blood. After several hours he revived, and dis- 
covered that the left arm and hand were sensitive through- 
out. On the radial side of the forearm there was slight 
numbness, — a condition compatible with perfect tactile 
sensibility. Motion appears to have been lost, or greatly 
lessened during some hours, and within a day to have be- 
come restored entirely. No doubt exists as to this point. 
No dressing was used until the third day, when water 
was applied. At this date the arm motions were com- 
plete below the shoulder, and there had been no pain. 
Soon after the cold dressing, to which he attributed the 
sequent symptoms, he was seized with neuralgic pain, 
which was principally in the median nerve distribution, 
but also on the outside of the arm and shoulder, with a 
spot of intense pain at the deltoid insertion. The pain 
was darting and pricking in its nature. Coincidently with 
the pain, the joints of the fingers swelled and became sore, ILLUSTRATIVE CASES. 
213 
and this was especially the case with the thumb and the 
first and second fingers. At the same time the shoulder 
muscles became weak, flexion of the fingers grew feeble, 
and the flexion of the forearm was affected. All of these 
defects increased for several months, and the flexor group 
in the forearm wasted so much as to attract attention. 
The biceps, brachialis anticus, and coraco-brachialis were 
in like manner atrophied. The pectoralis major was also 
thus altered at a still earlier period. Up to the eighth day 
the patient spat blood freely. Then it ceased, and he has 
had no pulmonary difficulties of any kind since. 
February 19, 1864.—Admitted. 
Atrophy of pectoralis major is great, of the shoulder 
muscles slight; wasting of biceps and other anterior and 
internal arm muscles is considerable. The left arm at the 
biceps measures ten inches; the right, eleven and three- 
fourth inches; the left forearm, ten inches; the right, 
eleven inches. The left hand congested, dark, and cold; 
is easily chilled. 
Sensation is perfect. The neuralgia has nearly disap- 
peared, except in bad weather, and about the insertion of 
the deltoid, where there is great tenderness, and a good 
deal of hardening and deposit in the subcuticular tissues 
and over the bone. The only muscle which is hyperses- 
tlietic to any marked degree is the biceps. The course of 
the museulo-cutaneous and the median nerves is acutely 
tender upon pressure. 
There is no motion in the pectoralis major, and it is 
scarcely perceptible in the biceps,—the supinator longus 
alone flexing the forearm. Extension of forearm is per- 
fect. The fingers act in flexion feebly, but are improving. 
The thumb motions are also weak, but not lost. Motion 
is now most limited by the state of the finger-joints, which, 
although no longer tender, are stiff and enlarged. So 
much improvement has taken place very recently that we 214 
INJURIES OF NERVES. 
cannot be sure as to what motions were lost. Probably 
the principal nerves of the external cord of the plexus— 
namely, the musculo-cutaneous and the median—were 
those chiefly affected ; certain filaments of the posterior 
strand, as the circumflex, also sharing in the diseased con- 
ditions. The remainder of the case would be irrelevant 
here. It was improving when admitted, and it gained 
ground with increased speed under a course of baths, 
gymnastics, and faradisation. CHAPTER IX. 
DIAGNOSIS AND PROGNOSIS OF INJURIES OF NERVES. 
Diagnosis.—In general, it is of course easy to say whether 
a nerve trunk has been directly injured or not. The well- 
known symptoms, together with an obvious lesion having 
a certain place or direction, usually tell us with sufficient 
distinctness the nature of the hurt whenever the accident 
has been seen in its earlier stages. Somewhat later, and 
in rare cases, the diagnosis of the initial injury may be 
difficult, owing to the reflex disturbance of remote nerves, 
and the fact already dwelt upon, that a subacute inflam- 
mation or a sclerotic state of nerve may pass centrally 
from the nerve first in fault, and thus come to affect one 
or more cords of the parent plexus. Whatever doubt I 
may once have had as to this tendency of inflammatory 
changes to travel inward, has been set at rest by the 
repeated instances which I have recently encountered. 
At the Hospital for Deformities and Nervous Diseases, 
I have lately seen a girl who met with an injury which 
affected an elbow already anchylosed, in consequence 
of which the nerves, especially the musculo-spiral, be- 
coming sore, the arm grew hypenesthetic, and severe 
aching neuralgia set in from the middle arm region to 
the finger-ends. This was entirely relieved by extensive 
counter-irritation with strong liniments. Very soon after- 
wards the circumflex nerve became involved, and the del- 
toid rapidly wasted. In this case, the local injury at the 216 
INJURIES OF NERVES. 
elbow mast have traveled up to the plexus and thus in- 
volved the shoulder branches. 
Far more uncommon are the cases in which a bullet 
has split, and one fragment or a piece of splintered bone 
has implicated some distant nerve. Perhaps there exists 
no more interesting instance of this than the case of Sey- 
mour, which I transfer from my Report to the Sanitary 
Commission as a rare illustration of the difficulties which 
this singular accident may introduce into the diagnosis of 
a case. 
Case 39.— Wound of left neck and jaw ; loss of speech and 
deglutition; secondary hemorrhage; attempted ligature of right 
primitive carotid followed by palsy of right arm ; anaesthesia of 
right side of jaw and face; loss of gustation in right side of 
tongue, also of touch, pain, and thermal sense ; no loss of mo- 
tion in right side of tongue; left side of tongue paralyzed as 
to motion only and atrophied; section of left lingual nerve, 
of hypoglossal, and of right lingual branch of glosso-pharyngeal 
nerve; injury by splinter of bone to inferior branch of fifth 
nerve; recovery. Wm. Seymour, aged twenty, sailor. 
On May 5, 1865, in the Wilderness, while ramming a 
load, he was shot from the branches of a tree on his 
left. The ball entered one and a half inches imme- 
diately below the left auditory meatus, touching the 
lower lobe of the ear; it slightly splintered the posterior 
angle of the lower jaw-bone, and passed across the throat 
much below the level of the tongue, though as to its 
exact path little is known. It made exit in the right 
side of the neck at a level with the lower edge of the 
thyroid cartilage, through the sterno-cleido-mastoid mus- 
cle, about one and a half inches above the clavicle, and 
two and a quarter inches from the middle line. lie fell 
senseless, lay thus about an hour, and then awakening, 
crept half a mile, as he thinks, both wounds bleeding in 
jets. lie now tilled the wounds with dust, and so checked DIAGNOSIS AND PROGNOSIS OF INJURIES OF NERVES. 
217 
the bleeding. He thinks both arms were at this time 
equally strong. The third night his wounds were dressed. 
Up to this time he had taken no food, and most of the 
water which he drank ran out of the right wound in the 
neck. He was taken to the Douglas Hospital on the 10th 
of May. 
At this point I insert the letter which Seymour brought 
with him from the accomplished surgeon in charge of the 
Douglas Hospital, Dr. ¥m. Thomson, U. S. A., at whose 
request the patient was transferred to the United States 
Army Hospital for Diseases and Injuries of the Nervous 
System. 
After describing the wound, Dr. Thomson adds: 
“For a number of days he was nourished by injections 
of beef-tea, and by small quantities of milk introduced 
into the stomach through a catheter. lie had had a 
severe hemorrhage on his way to the hospital. Ills wounds 
were dressed with cold water. 
“ May 19th.—He had a secondary hemorrhage, and 
lost eight ounces of blood. This was checked by com- 
pression. 
“May 26th.—Lost four ounces of arterial blood from 
the wound of exit and from the mouth. The wound of 
entry was closed. Small bleedings occurred each day 
upon the least exertion, until May 30th, when it became 
evident that some operation would be needed to save his 
life. The external compression had caused an accumula- 
tion of blood about the trachea and neck generally, which, 
with other causes connected with the wound, made suffo- 
cation appear imminent. He was anaesthetized, and an 
incision made for ligature of the right primitive carotid. 
I should add that at this time there was good pulsation in 
the right temporal artery. After patient and thorough 
search, no trace of the right carotid, the internal jugular 218 
INJURIES OF NERVES. 
vein, or the pneumogastric nerve could be found. The 
incision was extended downward, and the sternal attach- 
ment of the sterno-cleido-mastoid muscle divided. The 
opening in the neck was finally carried up to the parotid 
gland, and the region thus exposed was submitted to the 
closest scrutiny, but still without discovery of any large 
vessel. As the oozing still continued, I made fruitless 
search for anything large enough to tie, and at length 
filled the wound of exit with charpie, and left the patient 
to his fate. No further bleeding took place, and recovery 
was henceforward rapid. 
“For a long time there was complete aphonia, and 
after the operation he lost power in the right arm.” 
Admitted at Turner’s Lane Hospital, September 11, 
1865. 
The following particulars were elicited : 
Wounds closed. Right arm: sensation and motion 
feeble throughout the limb. I believe this to have been 
due to changes in the brachial plexus in the neck, conse- 
quent upon the operation. The neck has, from stiffness, 
only one-quarter range of movement. Face: touch is 
lost on right side of face, cheek, skin of lips, from half an 
inch in front of ear to line of external angle of right eye. 
Worst on edge of chin, fair on red part of lips, limited 
by middle line. Touch lessened on upper neck. Anal- 
gesia, moreover, less complete in all these parts. The 
nose is unaffected. Tongue : on the right side there is 
absolute loss of gustation, touch, pain, and sense of tem- 
perature. This defect is limited by the middle line. Very 
far back there appears to be considerable sensation. On 
the right side motion seems entire; and the right side of 
the tongue is firm, red, and well nourished. The left side 
of the tongue is paralyzed as to motion almost entirely. 
It is soft, flabby, wrinkled, and atrophied, rolling help- 
lessly with the movement of the right muscles. The DIAGNOSIS AND PROGNOSIS OF INJURIES OF NERVES. 
whole tongue, when at rest, lies straight in the mouth, 
but it cannot now be projected. When, early in the case, 
this was possible, it turned distinctly to the left side. 
Deglutition is imperfect; he has to take moistened food 
only, and coughs and chokes very frequently while eat- 
ing. He is liable to tits of gaping when tired or over- 
heated. Voice nearly perfect. The eyes are healthy. 
There is no pain anywhere. The heart and lungs are 
sound. Appetite and digestion good. 
It is clear, from the facts before us, that the ball 
cut the left hypoglossal nerve and also the right lin- 
gual branches of the glosso-pharyngeal nerve. The 
former accident sufficed to palsy the left side of the 
tongue. The latter may be assumed to have had some 
share in the destruction of gustatory sensation on the 
right side of that organ; but these accidents account 
neither for the accompanying total loss of tact and pain 
in the right side of the tongue, nor for that of the right 
side of the face. To paralyze sensation in the latter 
regions, there must have been either a secondary affec- 
tion through induced disease of the centres, or else a 
wound of the fifth nerve; and if the latter took place far 
enough back, it would involve some of the branches which 
go to the tongue, and some which supply the face. The 
question is answered, I think, by the following facts : 
Early in the case, Seymour felt a pricking in the right 
side of the throat, far back. At the fourteenth day a piece 
of bone, half an inch wide, and very thin, escaped into the 
throat from the part mentioned, and was coughed up. Un- 
fortunately it was not preserved. I suppose this splinter 
was broken off the left jaw, and driven across the throat 
so as to wound the third branch of the fifth nerve. 
Seymour’s recovery was rapid, although I used no 
treatment at all. 
October 10th. — The face has recovered sensation. 220 
INJURIES OF NERVES. 
Taste was restored to the tongue, although not perfectly. 
Tact and pain were still absent. 
October 20th.—There is some feeling in the tongue, 
but no motion on the left side, and no change in the nu- 
trition. 
Returned to duty, October 20, 1865. 
Reflected palsy in remote regions, the result of a ball 
wound, though rare, is not to be lost sight of. Nor should 
it be forgotten that when one nerve of a limb has been 
subjected to prolonged pressure, as in Waller’s experi- 
ments, the loss of power may not be limited to its own 
muscular distributions, but may also involve those which 
had not been primarily injured. This effect is too sudden 
to be ascribed to progressive neuritis. As yet I have not 
met with it in any clinical example of neural compression. 
Loss of function in a part is usually sufficient to indi- 
cate what nerve has been injured, and to what degree; 
but as regards the hands, and perhaps also the feet, this 
would seem to be less valuable as a diagnostic means 
than might at first be supposed. There are, for example, 
rare instances in which section of the median has failed 
to cause loss of sensation or motion in the regions to 
which it is commonly distributed, while in other cases, 
quite as uncommon, the return of function after section 
has been so rapid as to have cast doubt upon the fact of 
total nerve division, had this been other than certain. In 
the vast majority of instances, however, the loss of motion 
in some muscles, and the defect of sense in definite skin 
spaces, will positively tell us what nerve has been hurt, 
and also the extent of the lesion. 
In case of doubt as to the completeness of the nerve 
section, or in any of the anomalous examples of ap- 
parent division with continuance of sensation in the dis- 
tal distribution of the hurt nerve, the use of faradaic cur- 
rents applied to the nerve above the wound would surely DIAGNOSIS AND PROGNOSIS OF INJURIES OF NERVES. 
221 
settle the question as to whether or not it was really cut 
across; since if it were, it would be impossible, by this 
agent, to excite its related muscles. It were also well in 
cases like Nelaton’s or Hott’s* to try if, by electricity 
applied to the unharmed nerves, we could excite muscles 
usually controlled alone by branches belonging to the 
nerve injured. The results, whether negative or positive, 
would be full of interest. 
M. Tillaux has made some effort to point out how we 
may distinguish the various forms of injury, as commotion, 
contusion, compression, and partial section. Of course 
the history of the injury may be such as to make need- 
less this inquiry ; but it often happens that, with evidence 
of functional loss or injury, there is some possibility of 
intra-pelvic or other interior pressure, or else we may 
have a history of mechanical injury with that of some 
other probable cause of neural lesion. 
As an example of this, I saw a short time ago a fine little 
fellow, who had a slight draggingof the right leg, follow- 
ing upon a fall. On inspection, however, I noticed that 
the affected leg was the smaller, upon which a careful 
questioning disclosed the fact that the child must have 
halted a little for some time. Then, finally, I learned that 
he had had, several months before, a severe attack of typh- 
litis, with great swelling and hardness in the right pelvic 
region. The fall was too recent (forty-eight hours) to 
have caused atrophy, which was very distinct. I con- 
cluded, therefore, that the nerves must have suffered from 
the gradual pressure of the confined and engorged tissues 
about and below the gut. Certainly no single symptom 
of pain or numbness indicated the progress of the evil, so 
that here, as in many other cases, a very gradual pressure 
proved competent to occasion grave nutritive and some 
* See chapters on Treatment. 222 
INJURIES OF NERVES. 
motor loss, with no distinct warning in the way of sen- 
sory disturbances. 
I have, indeed, great doubt as to our capacity to distin- 
guish the form of injury from the resultant symptoms 
alone. In a recent case, where there was the probability 
of intra-pelvic neuritis from cancer, and the certainty of a 
fractured thigh, with great amount of callus, so situated 
as to make likely some nerve pressure, I was unable 
positively to ascribe the signs present to either- possible 
cause. 
There are so many ways in which slow intra-pelvic 
pressure on nerves may occur, that a sure test of the 
presence of compression has always been most desirable. 
As regards the accepted signs of pressure, it is quite 
clear that, when clinically applied, they are not competent 
to guide us, because the various degrees of pressure may 
bring about, as we have seen, the utmost variety of symp- 
tomatic results. In proof of this I need only refer to the 
case of the lad lately quoted, and to the various histories 
of nerve pressure already related. 
Still more important, practically, is the decision as to 
whether certain neural symptoms be due to central dis- 
eases or to peripheral causes, such as intra-pelvic or other 
pressure. When the question lies between nerve lesion 
and cerebral disease, it is, as a rule, easily settled. Cere- 
bral palsies have a peculiar history, are sudden in their 
onset, and are more often destructive of motion alone 
than of this with sensation. They are also more pecu- 
liarly distinguished by the fact that in them the muscles 
remain excitable under electric currents. Indeed, in the 
early stages of cerebral palsies with tendency to contrac- 
tion (early rigidity), they are over-excitable, while the in- 
stances in which, late in old cases, they have their electric 
excitability lessened are very rare, and depend, I suspect, 
upon some of those singular peripheral neural changes DIAGNOSIS AND PROGNOSIS OF INJURIES OF NERVES. 
223 
which have been lately shown to attack in such cases the 
peripheral nerve trunks. Perhaps the facts, as to non- 
growth or lessened growth of the nails in cerebral palsies 
which I have recently pointed out, may aid in doubtful 
diagnosis. On the other hand, very soon after an}- grave 
peripheral nerve lesion, there is sure to be great loss of 
power in the muscles to respond by movement to faradaic 
currents, and, a little later, to the galvanic currents. These 
facts will usually enable us to separate cases of cerebral 
palsy from those the origin of which lies below the brain. 
I was consulted lately in regard to a lady, aged forty- 
three, who, four years before, had a slight left hemiplegia, 
the recovery from which was unusually complete. A few 
weeks since she began to suffer from numbness of the left 
foot and leg, followed by increasing and rapid loss of 
power to flex the foot. Her attendant suspected a return 
of the cerebral disorder, but on electrically examining the 
peroneal muscles they were found to have lost power to 
respond to the battery. We then insisted upon a vaginal 
examination, when she was discovered to have a large 
growth behind and to the left of the womb, and of a 
somewhat suspicious nature. The local palsy was proba- 
bly due to this mass. 
The differential diagnosis of spinal disease from periph- 
eral lesions presents greater difficulties, and is more apt 
to give trouble than any of the other questions I have 
mentioned. Given a case of numbness and partial paral- 
ysis, is it due to nerve disease or to some spinal altera- 
tion ? If the former, it will probably, but not surely, be 
unilateral; and if the latter, it will be likely to be bi- 
lateral, and to affect both feet. For example: if the 
cause should be one affecting only a limited region of 
the spine, the lower ganglia being left unaltered, the 
muscles will retain their electric irritability, which is not 
the case when these lower portions of the spine become 224 
INJURIES OF NERVES. 
themselves largely diseased,—a fact which must be settled 
by other symptoms connected with the existence of anal- 
gesia and the absence of reflex motions. In certain cases, 
then, of spinal disease, the muscles continue to respond to 
some form of current, and do not waste; while in others 
the reverse occurs, just as in injuries of extra-central nerve 
trunks. 
When cutaneous anaesthesia exists, it is often easy to 
learn whether its cause lies in the nerves or the central 
organs by following the plan proposed by Stich.* If the 
insensible region can be made the point of departure of 
reflex movements, the anaesthesia is of central birth, be- 
cause to have reflex motion an excitation must have 
reached the spine, by which we infer healthy nerves, 
while the mere presence of the anaesthesia will, in this 
case, indicate the existence of disease in the spine above 
the point which is the seat of the reflex power exhibited. 
If the proof be negative, and if the excitation cause no 
movement, we can arrive at no definite conclusion, until, 
following the same sensitive nerve up the limb, and by 
seeking to excite through it reflex acts, by touching the 
skin with a hot sponge or ice at successive points, we learn 
if at any upper portion of tegument we can produce this 
result. Should we get an affirmative reply, we may pre- 
sume that the anaesthesia is of peripheral origin. When, 
finally, the answer is negative up to the spine itself, we 
learn nothing by this method, the total absence of all 
reflex movement being equally compatible with either 
loss of conducting power in the peripheral trunks and 
branches and with extensive alteration of spinal centres. 
The value of this means must be necessarily limited by 
the difficulty of exciting reflex acts from all regions of skin. 
* Empfehlung der Erregung von Reflexbewegungen als diagnostisches 
Hilfsmittel (Annalen des Cbarite Krankenhauses zu Berlin, 1856.) Also 
Jaccoud, Paraplegies, p. 498, whence this account is taken DIAGNOSIS AND PROGNOSIS OF INJURIES OF NERVES. 
225 
There is another peculiarity which separates all extra- 
central nerve lesions from cerebral, and also from spinal 
disease; but I do not feel that as yet it is available to any 
large extent. I noticed some years ago that in even the 
gravest lesions of nerve trunks if a touch were felt at all, it 
was felt with no remarkable delay; while in many central 
palsies, if severe, and especially in such as result from 
extensive spinal malady, the time required for transmis- 
sion to the sensorium was, as .Cruveilhier pointed out, very 
largely increased,—so much so, indeed, as to be readily 
estimated in a rough way by the hand of a watch beating 
quarter seconds, or still better by a metronome. The 
cause of this difference is still obscure to me, nor is it 
easy to see why diffuse sclerosis, for example, should so 
retard a sensory impression, while injured nerve fibres 
have no such effect.* 
Prognosis.—The form of injury to the nerve has a large 
influence upon the prognosis, which, however, is always 
grave, so far as complete functional recovery is concerned, 
in every instance of severe nerve lesion. In the larger 
number of cases of pressure by growths, such as exos- 
toses, aneurism, or intra-pelvic tumors, the ultimate fate 
of the case depends, of course, on our power to remove 
the cause of pressure. 
For reasons not as yet clear to me, a contusion is often 
apt to give rise to more prolonged and serious injury than 
other forms of mechanical disturbance apparently more 
capable of locally destroying the nerve. Probably a 
bruised nerve is more likely to pass into neuritis than 
even one which has been wounded. 
Partial nerve wounds have been considered more serious 
than entire division, but to this I can scarcely give a full 
assent. The cases of intense neuralgia from lancet wounds 
* See San. Com. Med. Eeport, p. 438. 226 
INJURIES OF NERVES. 
of sensory skin filaments have been held to support the 
opinion I am combating, but probably the pains are due 
to reflex radiated irritations; nor is there the slightest 
proof, on the one hand, that such irritations may not arise 
from the ends of fully divided nerves, nor, on the other, 
is there any evidence that in these cases the minute nerves 
in question are merely pricked or half-way severed. It is 
certain, however, that partial nerve wounds of large trunks 
alone occasion many of the distressing nutritive condi- 
tions already described : but, so far as my experience goes, 
notwithstanding these results, such wounds have, on the 
whole, a more fortunate remote history than thoroughly 
divided nerves, where a missile of war has been the in- 
juring agent. 
The future of cases of entire severance of nerves will 
depend upon the amount of nerve cut away, the sequent 
neuritis, and the fate of the surrounding tissues; but even 
when the portion lost has been an inch or more, we should 
not absolutely despair of a large return of function, when 
we remember the extraordinary regeneration of nerves 
after exsections for neuralgia. 
Given a case of severe injury to a large nerve, how shall 
we make up our minds as to the probable future of the 
parts over which it presides? No early opinion is of 
value. All missile wounds bruise and disturb more nerve 
filaments than they cut, and these will, in a few days, re- 
cover their lost powers. This is why many muscles, which 
at first seem paralyzed, come again very early under 
volitional control. The extent of anaesthetized skin of 
most nerve wounds also lessens within a week. Gradually 
with the absorption of blood, if no neuritis interposes, 
these happy changes continue until, at last, in from a month 
to six weeks, we begin to be in a condition to judge what 
muscles are to be more permanently palsied, what skin 
spaces are to remain insensible. DIAGNOSIS AND PROGNOSIS OF INJURIES OF NERVES. 
227 
To determine the future fate of the limb, we resort to 
the induced and galvanic currents. If, according to Du- 
chenne, a muscle moves ever so little when faradised at 
a period thus remote from the wound, there is a fair 
chance of its recovery, — a chance which lessens in pro- 
portion to the difficulty with which it contracts under this 
stimulus. If, however, a muscle neither moves nor feels 
the pain of the current, this is an indication of so com- 
plete a separation from the centres, that from three 
months to a year may elapse before the probability of 
nerve restoration becomes such as may enable us to call 
the part into action. This refusal to respond to the fara- 
daic current does not imply a certain loss of ability to act 
under galvanism, or of such mechanical irritation as a 
smart tap. In grave cases, however, there comes a period 
when the muscle may be dead to every form of excita- 
tion, and even to the direct effects of galvano-puncture. 
My colleagues and myself had many chances of testing 
the value of these means, and finally we learned to rely 
upon them with the utmost confidence. 
The sensibility is to be examined with the electric 
brush, and if found, after two or three sittings, to be 
dead to this most intense irritant, we may safely conclude 
that the nerves of the part are absolutely cut off from 
their central connections, and will require long periods 
for their repair, should this be ever possible. Unhappily 
the future dangers of the case do not end here. Apart from 
the chance of neuritis, which is, I am sure, a more com- 
mon sequence than has been supposed, there is no time 
for some weeks after the healing of the original wound 
when the part may not begin to suffer from neuralgia or 
causalgia of indefinite duration, and from those obstinate 
arthritic states which so baffle our efforts to restore move- 
ment even when the healed nerves have made this other- 
wise possible. 228 
INJURIES OF NERVES. 
The contracted state of the atrophied muscles also 
comes into the case to make its future less hopeful, and 
the reader will see, therefore, why I think it needful in 
ever}7 instance to exercise an amount of caution as to 
prognosis which might at first sight seem scarcely war- 
ranted. 
At the same time I may add, that in the interval 
of three or four years, the gradual change which may 
occur in the worst of these cases is so great and so bene- 
ficial that only a careful study of many of them, with a 
comparison made from my note-books, could have in- 
duced me to credit the degree of restoration which time 
may bring about. In proof of this statement, the reader 
is referred to the cases appended to the chapters upon 
Treatment. CHAPTER X. 
TREATMENT. 
Compression.—The treatment of compression is obviously 
the simple one of removing the cause, which in examples 
of intra-pelvic pressure is often beyond our power. Cases 
of compression due to disturbances arising out of the 
altered mechanical relations of a diseased nerve during 
motion, are best treated by passive movements and the 
most gentle but thorough shampooing; while if there 
should seem to be, at any stage of the case, an inflam- 
matory state of nerve, absolute rest, enforced by a splint, 
with the usual treatment for neuritis, are required. 
Contusions.—Contusions of nerves, when severe, are apt 
to be followed in a few days by slight numbness and 
pricking, and when these are associated with growing 
tenderness over the nerve track, the physician should 
promptly interfere, since he may feel sure he has to deal 
either with the commencement of a neuritis, or of that 
sclerotic state of nerve which may or may not be of in- 
flammatory origin. In either case, the nerve can some- 
times be felt in thin persons as a firm cord, not always 
entirely regular in size. As I have said before, these con- 
sequences may follow contusion of nerves at dates as dis- 
tant as weeks or months, and may give rise finally to the 
most deplorable results. 
In a certain number of contusions the evil is most in- 
sidious, and, whatever be the pathological condition, it 
may result in large functional losses without any notable 
( 229 ) 230 
INJURIES OF NERVES. 
warning in the "way of pain or tenderness. One of the 
best illustrations I have seen of this was in the case of 
C. P., a man of intemperate habits, who bruised the ulnar 
nerve at the elbow by a fall in July, 1862. lie could use 
the limb next day, but for some months he had slight 
formication along the inside of the arm. In December, 
1862, the third and fourth digits became weak, and grad- 
ually the loss of power affected the entire hand and wrist. 
He was admitted to the hospital in June, 1863 ; at this time 
every motion below the elbow was feeble. The sensory loss 
was great in the ulnar track, and was increasing in the 
median distribution. Both the ulnar and the median nerves 
were exquisitely tender on pressure. The inflammatory 
condition awakened in the hurt nerve, some five months 
after the injury, passed up the arm high enough to affect 
secondarily the median nerve. Leeching and blisters 
always greatly relieved his neuralgic pain, and lessened 
as certainly the tenderness of the nerve trunks; but his 
incessapt drinking at last set all means at defiance, and he 
was finally discharged. The proper treatment for a con- 
tused nerve is absolute rest, with the use of leeches and 
cold water, when symptoms of neuritis declare themselves. 
The following case is a fair illustration of contusion of 
nerves and its treatment: 
Case 40.— Contusion of the right musculo-spiral nerve. Early 
in January, 1865, C. P., clerk, aged twenty-two, while 
fencing, was struck by the button of his opponent’s foil 
upon the middle and outside of the right arm. The shirt- 
sleeve was torn, and the flesh bruised severely. He felt a 
sharp pain, which subsided into a tingling in the thumb 
and outside of the forearm. This continued for several days, 
and on the tenth day became distressing. Upon examining 
his arm, I found that the motions of the index-finger were 
feeble, and that the wrist was extended with difficulty. 
The track of the radial nerve was sore, and the point on TREATMENT. 
231 
which the blow fell was exceedingly tender. Notwithstand- 
ing the deep situation of the musculo-spiral nerve, it was 
also tender upon pressure, and continued to be so for 
many weeks. I had the nerve tracks leeched twice a 
week, and used on the same days an injection of morphia 
and atropia over the radial nerve. These means partially 
relieved the hand; but the pain along the outer aspect 
of the arm became worse, and assumed an intermittent 
type, appearing every day after twelve o’clock. I used 
quinine, but to no purpose; and finally I placed him 
upon arsenic, giving six drops of Fowler’s solution thrice 
a day. Once a week, four leeches were applied over the 
injured part of the musculo-spiral nerve. The injections 
were only used when excess of pain demanded them, but 
an opium plaster was placed over the outside of the arm 
and forearm. These means proved successful, and the 
pain slowly subsided, after having lasted unchanged for 
four months. Exactly live months after the injury, his 
condition was as follows : 
Extensor power nearly perfect; no pain in hand; skin 
on outside of forearm a little sore to the touch, and sub- 
ject to slight daily pain, increased by fatigue and damp 
weather. The nerve tracks were still sore, but not ex- 
cessively so. At this time he began to have pain in the 
shoulder, tenderness below it, and distinct loss of power 
in the deltoid muscle. These new symptoms followed 
great exposure to bad weather, and were synchronous 
with a fresh attack of neuralgia. As he was now well 
and strong, as to general health, I put cut cups about his 
shoulder, and followed their use by a blister dressed with 
morphia. At the same time I confined him rigorously to 
his bed. These measures relieved the pain, but the fee- 
bleness of the deltoid increased, and the muscle lost bulk, 
so that, at the close of a month from this fresh attack, he 
could raise the arm but six inches outward from the side. 232 
INJURIES OF NERVES. 
Two weeks later, these changes ceased, and he began to 
improve so rapidly that, except? the exhibition of small 
doses of arsenic and local frictions, there was no occasion 
for more active treatment. I believe that this rapid relief 
was largely due to the coming on of warm spring weather. 
When last I saw him, early in the summer of 1865, he 
was suffering trifling pain in the arm at rare intervals. 
was no pain in the shoulder, but the deltoid was 
still a little flattened, and the extended arm could be 
raised only to the level of the shoulder. 
Looking at the anatomical relations of the musculo- 
spiral to the circumflex nerve, it seems fair to infer that 
the disease which first involved the former came finally by 
direct propagation to affect the latter. So far as the mere 
symptoms can inform us, such would seem to be, in this 
case at least, the true explanation of the secondary affec- 
tion which fell upon the shoulder. No opportunity has 
been afforded me of studying the morbid anatomy of 
nerves supposed to be thus altered: but I think the facts 
in favor of directly propagated nerve change are quite 
sufficient to render probable the theory I have here advo- 
cated, while for the idea of its being a reflex affection, 
there is simply no evidence at all. 
The changes which finally occur in sensation and mo- 
tion from contusions or compression, differ in no impor- 
tant respect from those which arise out of direct injuries; 
so that for the treatment of these sequelae I may refer the 
reader to that portion of this chapter in which I have 
dealt with the therapeutics of symptoms. 
Punctured nerves; wounds of superficial branches.—Punc- 
tured wounds of nerves demand no especial treatment 
unless they occasion grave symptoms, which is by no 
means always the case. They are, moreover, very rare. 
I saw, some years ago, a woman who had transfixed the 
median nerve with a steel fork. The injury at once TREATMENT. 
233 
caused darting pain in the palm with quivering of the 
thumb flexors. I gave opium freely, dressed the wound 
with laudanum, placed the arm at rest on a splint, and saw 
the symptoms subside and disappear within two days. At 
present I should keep such a case well under the influ- 
ence of morphia with the aid of the hypodermic syringe, 
and prescribe in addition the local dressing described. 
Lancet wounds of the sensitive cutaneous nerves about 
the elbow we shall probably see no more until bleeding 
is partially restored to fashion, as it is sure to be. The 
older surgeons were accustomed to treat them by cautery 
at the point wounded : this was effected by placing a 
morsel of potassa fusa in the lips of the cut; while others 
made an incision above the wound or isolated it by carry- 
ing the knife around it. Both methods answered in many 
cases, while in rare instances, where no such means were 
used, excruciating pain and local spasms continued for 
weeks or months, until, as in Fare’s royal patient,. the 
symptoms gradually subsided, or some such operative pro- 
cedure was employed, as I have just mentioned. Swan* 
speaks of cases in which the relief thus obtained was 
instant and complete, and thinks that where the symp- 
toms are not immediate the trouble has arisen from too 
early use of the arm. He relates many slighter cases in 
which rest, warm opiate fomentations, and the local use 
of belladonna gave ready relief. 
Mr. Pearsonf reported in 1817 cases of extreme pain 
from lancet wounds, in which, after every other means 
had been exhausted, the most remarkable ease was 
afforded by the use of the following liniment: 
R.—01. Olivae, ; 
01. Terebinth inae, ; 
Ac. Sulphuric, fort. gi. M. 
* Swan on the Nerves, p. 117. 
f Med.-Chir. Trans., vol. viii. p. 252. 234 
INJURIES OF NERVES. 
It was employed repeatedly, and so as to cause the most 
intense inflammation of the skin of the whole arm. 
Where it failed to irritate sufficiently, he added a larger 
amount of the acid. Whatever value this treatment may 
have, and it seems scarcely possible to read Mr. Pearson’s 
cases without according it a large share of confidence, 
must be due to the extent of surface attacked by the irritant. 
Injuries by missiles of war.—The early treatment of this 
class of wounds does not require any special notice. The 
nerve lesion need in no way modify the dressings; and 
the amount of inflammation attendant upon ball wounds, 
and the subsequent destruction of tissue in the ball track, 
make it unnecessary to consider whether any of those 
immediate surgical interferences are demanded, which 
are at present among the doubts of surgery in regard to 
cases of clean incised wounds of neural trunks. 
Every possible precaution should be taken to lessen the 
chance of deep inflammation and the secretion of pus, 
since conclusive evidence has been obtained from experi- 
ments on animals, that nothing is more fatal to reunion 
of nerves than the formation in the wound of large 
amounts of matter. 
Incised wounds.—An incised wound partially involving 
a nerve, should be carefully cleansed from fragments of 
glass or other foreign bodies, the lips brought together as 
usual, and the limb set at absolute rest on a splint, with 
every precaution to relax the tissues, and to keep the 
nerve ends from being drawn apart. Thus, in a wound of 
the ulnar at the elbow, the arm should be kept in exten- 
sion, and a wound of the anterior nerves should exact a 
state of repose in flexion. These measures are rendered 
necessary in every case by the tendency of the nerve ends 
to separate, for every healthy nerve is in a state of slight 
tension, and, on being cut, the extremities tend to draw 
apart. TREATMENT. 
235 
Sutures in nerve wounds.—Where it is plain, from a care- 
ful study of the wound and the loss of function, that the 
nerve trunk has been altogether divided, the surgeon is 
called upon to decide whether he will leave repair to 
nature alone, or enlarge the wound and secure coaptation 
of the nerve ends by the use of sutures. The propriety 
of this step rests upon the manner in which we answer 
these two questions: Will any, even the most perfect, 
approximation of nerve ends insure immediate union ? 
and, failing this, will it make likely a more speedy return 
of healthy function ? To the first, we may give a certain 
negative; to the second, we may, with some confidence, 
reply in the affirmative. 
As I have already pointed out, all the physiological evi- 
dence is against the possibility of immediate useful union. 
Within a few days the peripheral end of the nerve surely 
degenerates, and in adult animals many months may pass 
before it is restored and the two ends reunited. Even in 
young animals the earliest re-establishment of function, 
when the ends were made to touch by suture, was seven 
or ten days (SchifF), and nine days (Magnien). Vulpian 
has no case within seventeen days; and I have never met 
with an instance even in so short a time as this. The phy- 
siological facts are therefore opposed to the probability of 
immediate union; but, on the other hand, we are met by 
the statement that these were derived from lower animal 
life alone, and that in man the rule as to the time de- 
manded for restoration may meet with exceptions, and 
this possibility is supported by certain clinical histories 
which may not be altogether set aside. 
In 1863, Paget reported two cases of nerve section in 
children, aged respectively eleven and fourteen years. 
The first had the median and radial nerves divided by a 
clean cut from a circular saw. The wrist was placed in 
flexion on the forearm, and after ten or twelve days there 236 
INJURIES OF NERVES. 
was slight feeling in the median distribution. At the 
close of a month sensation was still very obscure in the 
thumb and forefinger, and some parts of the skin were 
insensible. A year having passed there was still no feel- 
ing in the last phalanx of the thumb and forefinger, 
but elsewhere in the median distribution sensation was 
almost perfect. 
The second lad had his hand so nearly cut off at the 
wrist that it remained attached to the forearm by only a 
portion of skin an inch wide, connected with which were 
the unhurt ulnar vessels and nerve, and the flexor carpi 
ulnaris muscle. The radial artery was tied, and the parts 
having been replaced, the limb was dressed with adhesive 
strips and put on a splint. In a week after the injury the 
hand had become warm again, and in ten or twelve days 
there was slight sensation in the fingers, but in the thumb 
none was discernible until more than two weeks had gone 
by. Finally, the sensation of the hand and fingers, and 
most of their movements, were perfectly restored.* 
Tillauxf is inclined to explain these two cases as in- 
stances of really rapid repair, such as SchifF describes as 
occurring in young animals, and would not regard them 
as examples of immediate union, with consequent escape 
from secondary degeneration. In other words, there was 
time here for such rapid partial alteration and regeneration 
of the distal ends of the cut nerves, as has been shown to 
be possible in the young of animals, while to constitute a 
truly immediate union we should have so speedy a reunion 
as to save the peripheral extremities from the certainty of 
Wallerian atrophy of their tubes. 
Perhaps the following observation may best illustrate 
how unlikely is immediate union to take place under even 
* Paget, Surgical Pathology, Am. ed., p. 187. Phila., 1854. 
f Op. cit., p. 89. TREATMENT. 
237 
the most favorable circumstances, and where young ani 
mals are used. I laid bare the sciatic nerve of a young 
rabbit, and with a cataract needle divided the middle 
fibres of the nerve. There was no bleeding, no retrac- 
tion, and the lips of the little wound thus made lay in 
close apposition ; yet, on examining the distal end at the 
close of six days, I found a large number of fibres under- 
going retrogressive changes. 
In June, 1864, M. Houel reported to the Society of Sur- 
gery, at Paris, the following case of Helaton’s, which I 
quote, with some abridgment, from Tillaux: 
“A female, aged twenty-four years, suffered from a 
neuroma, situated at the internal and upper part of the left 
arm, and involving the median nerve. After removing 
the tumor, M. Helaton united the two ends of the divided 
nerve by two metallic loops. It was then found that she 
had lost the power to move the thumb and first and second 
fingers, the other two retaining their motility. There was 
no sensibility to touch in the median distribution, but the 
sense of pain and that of temperature do not seem to have 
been examined. On the third day she complained of pain 
in the thumb, index-finger, and medius. She could now 
bend slightly the first and second fingers, but could not 
move the thumb. Sensibility to touch was unaltered on the 
palmar face of these members. On their dorsal face sen- 
sibility was absent in the two last phalanges, and pre- 
served in the first, while on the outside of the thumb it 
was rather more distinct. The threads were removed, 
and on the seventh day she could flex easily and rapidly 
the three fingers to which the median passes, and could 
bring the thumb into apposition with the first and second 
fingers.” 
We learn nothing further as to the fuller return of sen- 
sibility in the parts concerned, while the mode of exam- 
ination, where noted at all, is said to have been by pass- 238 
INJURIES or NERVES. 
ing a ribbon over the surface. Nothing could have been 
less satisfactory. With regard to motion, the interoseii of 
these fingers are fed largely by the ulnar, and their share 
in bending the first joints is well known. As to the appo- 
sition of the thumb, the inner half of the flexor brevis 
pollicis and the adductor pollicis also obey this latter 
nerve, and may well have been concerned in causing 
these motions. Tillaux, in criticising this case, remarks 
upon the supposed return of motion before that of sensa- 
tion,—the reverse of the common rule in traumatic palsy. 
I am unable to concede that there was here any positive 
proof of return of motion in the median distribution, and 
as to sensation, the examination unhappily leaves every- 
thing to be desired in the way of accuracy. 
In June, 1864, Professor Laugier reunited by suture a 
divided median nerve on the day following the accident 
which severed it. “ From the following night sensibility 
reappeared in the paralyzed parts. The day after, the 
thumb had recovered its power to oppose the index-finger, 
and the sensibility was much more lively.” 
On the eighth day, movement, sensation of touch and 
of temperature had returned; “ nevertheless, a 'pin 'plunged in 
the palmar face of the medias caused, no pain.”* 
It is much to be regretted that this, like the former 
case, should have been left so incomplete. I agree with 
Tillaux in his suspicion that the analgesia leads us to sus- 
pect that the observer was deceived as to touch and tem- 
perature, and that these were perceived through the 
nerves which feed adjoining tracts of skin. lie remarks, 
also, that the section was so low as not to involve the 
muscular branches, so that it is not surprising that the 
flexors of the fingers should still have enjoyed motion. 
In like manner, by the integrity of the median muscle 
* Tillaux, op. cit., p. 92. TREATMENT. 
239 
nerves, and of the ulnar, are to he explained the motions 
of the thumb. Let us add, that when seen by Vulpian 
on the fifteenth day, he could find no trace of sensation 
in the median tract, and that, according to Magnien, who 
saw it seventeen months after the operation, sensation 
was not even then normal. We are told by Tillaux* that 
since this case occurred Nelaton and Verneuil have both 
used the suture in divided median nerves, but without 
even the approach to success above recorded. 
The evidence thus offered by surgeons is too open to 
criticism to allow of our admitting that severed nerves 
may unite by immediate union; but even should we 
accept the facts as stated, they may still be explained 
with the aid of the recent researches of Arloing and 
Leon Tripier,f which have shown that, in the dog, and 
some other animals, the connections in the extremities 
between the various sentient nerves is such that the 
division of one trunk by no means annihilates sensation 
in the parts to which it is distributed. As yet, the evi- 
dence for a like arrangement in man is incomplete; but 
we are not without a few cases which, together with those 
above quoted, seem to make it probable that in man some 
such exceptional distribution of nerves may occasionally 
be found to exist. PauletJ relates several instances which 
favor this view. M. Richel reports a case of entire divi- 
sion of the median, in which the sensibility of the thumb, 
index, median, and ring fingers was preserved entire. 
In the example given by Baudens, sensation continued, 
despite section of all the brachial nerves save the radial. 
MM. Leudet and Delaboit saw a man in whom, thirty- 
seven years after the median had been severed, a post- 
* Op. cit., p. 95. 
f liecherches sur la Sensibilite des Teguments et des Nerfs de la Main. 
Arch, de Physiologie, 1869, p. 32 etseq., and 308 et seq. 
J Gaz. Hebdomadaire, No. 18, 1868. 240 
INJURIES OF NERVES. 
mortem examination proved that there had been no re- 
union, yet during this period the sensibility in the area 
supplied by this nerve remained unaltered and entire. 
Pirogoff* relates a case in which he divided a softened 
ulnar nerve during a resection, and found immediately 
afterwards, and at a later date, perfect feeling in the third 
and fourth fingers. He quotes,f also, Naudorfer and 
Schuh to like effect. Dr. Hott;}; adds to our list of sections 
without disturbance of function the following history: 
Case 41.—M. Wysinger, aged fifty, of robust constitu- 
tion, consulted Dr. 1ST. for a tumor on the forearm, which, 
although existing for fifteen years, had given no incon- 
venience until three months before, when it caused pain 
and partial contraction of the third and fourth fingers. 
The tumor was as large as a cocoanut, and extended 
from an inch below the elbow to within an inch of the 
wrist. This mass turned out to be a huge sac full of 
grumous blood, and was traversed on its exterior by the 
flattened fibres of the median nerve. The tumor was 
removed, and with it Jive inches of the median nerve ; but 
the functions usually assigned to this trunk were not in- 
terfered with in the slightest degree,—“neither paralysis 
nor loss of motion” ensuing. The neuralgia disappeared, 
and at no time afterwards was there any disturbance of 
function. Perhaps this is the most remarkable of all of 
these singular histories, and it is much to be regretted 
that its reporter should not have given more ample details 
as to the precise sensory and motor conditions. 
The general evidence as to the immediate and con- 
tinued loss of function when nerves are cut, is so strong 
that even if we admit the cases of exception as correctly 
* Pirogoff, Military Surgery, p. 377. 
f Ibid., p. 30. 
% Bone and Nerve Surgery, Appendix. TREATMENT. 
241 
reported, and bring to our aid the explanation given by 
Arloing and Tripier, we shall have to conclude that in 
man such partition of function as they describe in ani- 
mals must be singularly rare. Thus, in one hundred and 
fourteen cases of nerve section which I have coll ected, there 
was but one instance of no loss of sensation or motion. 
These rare exceptions must, then, be referred to unusual 
nerve arrangements in or below the plexus, such as Krause 
has described in his monograph on Neural Anomalies.* 
The histories first quoted prove the innocuous nature 
of the ligature when properly applied to nerves, a con- 
clusion for which I felt well prepared, from having in two 
* Les Anomalies dans le Parcours des Kerfs chez I’Homme, par W. 
Krause et J. Telgmann, traduit par S. H. De La Harpe, Paris, 1869, p. 
38 et seq. 
According to Robin, tbe filaments which enter the touch-corpuscles arise 
from terminal loops formed by the median and radial. Wenzel Gruber 
(Archiv fiir Anat. Phys. und Wissenschaft Med.,iv. p. 501-522, 1870, in 
Schmidt’s Jahrbiicher, Bd. cl. 1871, pp. 8, 9.), to clear up the variety 
of statements in regard to anastomoses between the ulnar and median 
nerves, examined one hundred male and twenty-five female bodies. An 
anastomosis took place in ten on both sides; in eighteen on one side 
(right, 4; left, 14). It is, therefore, normal once in five-sixths extremi. 
ties. In thirty-six cases there was one anastomotic branch, and in two a 
double branch. Generally, there is a branch from the median to the ulnar. 
Sometimes there is one from the ulnar to the median, which forms a loop 
with a downward convexity. 
In certain cases the median branch divides, one returning as a loop and 
one joining the ulnar. This anastomosing filament supplies the flexor 
profundus. It runs from the median to the ulnar below the pronator 
teres, and between the flexor sublimus and profundus, and either crosses 
or accompanies the ulnar artery, joining the ulnar nerve from one and 
three-quarter inches below the epitrochlea to the lower third of the fore- 
arm. Its presence does not influence the arrangements of the palmar 
anastomoses. The author refers to Krause, op. cit.,andto Roland Martin, 
Institutiones Keurologicae Ilolmise, 1763. 
Messrs. Pye-Smith, Howse, and Davies-Colley (Guy’s Hospital Reports, 
1870) describe as a variation from the normal, a branch between the ulnar 
nerve and the anterior interosseous of the median. 242 
INJURIES OF NERVES. 
cases left in the nerves of dogs metallic sutures which 
were never removed, but which apparently gave not the 
slightest annoyance after the nerves had reunited. M. 
Vulpian* regards neural suture as harmless, and thinks 
that the opposite opinion held by Eulenberg and Londois 
must have been due to their use of the rabbit only, an 
animal which bears badly all nerve lesions. 
The evidence in favor of regarding nefcve suture as not 
injurious, is therefore ample when we unite the clinical 
and physiological statements, both of which seem to 
decide very conclusively that after its employment the 
time needed for healing is notably lessened. The case of 
Verneuil, already alluded to, is further cited by Tillaux 
and Paulet to support this view. Both ulnar and median 
had been severed, but the suture was used in the latter 
alone, with the result of rapid return of sensation for 
parts fed by the median, and very slow sensoiy restora- 
tion of the ulnar territories,—exactly the result which has 
attended the physiological use of the suture. There 
seems, therefore, to be justification for the employment 
of sutures in any nerve wound, and especially where 
there has been loss of substance, as after removal of a 
neuroma. 
The mode of using the suture is important. Nelaton 
found it difficult in his first case to remove the threads. 
In his second case he passed a thin silver wire through 
the ends of the nerve within three millimetres of the cut 
surface, so that being drawn upon, the faces of the section 
wrnuld meet and not ride over one another, as they might 
have done had he followed Laugier in passing his thread 
remote from the cut. The ligature drawn through one end 
of the nerve returns through the other, and the two ends 
were imprisoned in a long tube of Galli, which reposed 
* Tillaux, p. 96. TREATMENT. 
in the wound on the nerve, or very close to it, and pro- 
jected from the wound so as to allow the operator to fasten 
his wires by bending them hooklike over the edges of the 
tube. In disengaging the loops, it was only necessary to 
lift the tube from the wound, and, releasing one end of the 
wire, to draw upon it gently. 
Vulpian uses in animals a single linen thread, which he 
carries with a fine needle from the upper side of the nerve 
obliquely through it, so as to come out about the middle 
of the cut surface. It is then passed through the middle 
of the exposed face of the opposite section and out at its 
upper side, so that when the loop is made and drawn, it 
brings the ends in exact apposition if the needle has been 
made to penetrate precisely corresponding points of the 
two faces.* 
I myself used in animals, some }7ears ago, a different 
method. In place of transfixing the nerve, I carried the 
needle through the loose tissue, which is related to its 
sheath, sometimes using one thread, and at other times 
two, one being placed on either side. By drawing the 
loops with care, it was possible to bring the nerve ends 
into close relation. With rabbits it does not answer, 
because of the small amount of areolar tissue about their 
nerve trunks. 
When, by suture and position, or other means, we have 
placed a nerve wound of any kind in the most favorable 
condition for healing, we shall find that no matter how 
well exceptional cases may do, we shall usually have to 
treat defects of motility and mobility, altered states of 
sensibility, and sometimes nutritive changes. 
* For all that refers to nerve suture I am largely indebted to Tillaux. CHAPTER XI. 
TREATMENT — CONTINUED. 
Loss of motion.—We have already seen how motion, at 
first altogether lost, in cases of partial lesion reappears 
in certain muscles, so that after a time we may know 
what muscles are permanently palsied. Both for pur- 
poses of diagnosis and of treatment, it is well to faradise 
the part at the close of a fortnight, if the wound he 
such as to admit of this. We shall then discover that 
certain of the muscles respond readily, and others not at 
all, while some revive after two or three sittings. These 
latter have probably been isolated from the centres for 
a time by mere mechanical disturbance in their con- 
necting nerves. Those which refuse all answer are com- 
pletely cut off from the spine by section or grave injury 
of their nerves. While making this statement, I do 
not wish to assert, with Duclienne, that the muscular irri- 
tability is lost because the muscle does not stir when far- 
adised, for Vulpian has shown that in rabbits, where a 
nerve has been cut, and the isolated muscle, faradised 
through the clean and shaven skin, does not move, a 
current applied to the exposed muscle will cause it to 
shorten. 
Even after several weeks, the muscles in man may be 
made to exhibit some contraction by passing electricity 
directly through them with the aid of needles.* More- 
over, galvanism will oftentimes elicit an answer after in- 
* Landry, Traite complet des Paralysies, t. i. p. 103. Paris, 1859. TREATMENT. 
245 
duced currents have failed, so that Duclienne’s dictum, that 
after ten days of separation the muscles in man no longer 
reply to the most intense electric current, is scarcely 
correct. 
Where no doubt exists that the whole nerve has been 
severed, the case is more simple. The muscles begin to 
lose irritability very early,* and continue to do so until 
their power to move under irritants is extinct, and only 
to be reawakened usefully by a repair of the connected 
nerves. 
Meanwhile the muscles, thus set at rest, undergo atro- 
phy, and, in some cases, shorten, while their sensibility to 
pain is lost, and the supply of blood diminishes, as it is 
sure to do in tissues which are no longer in a condition 
of functional activity. 
According to Duchenne, it is useless to faradise muscles 
so situated, until many months have elapsed and the nerve 
has had time to undergo a process of repair and reunion. 
At the IT. S. A. Hospital for Injuries and Diseases of the 
Hervous System, we very early reached the conclusion 
that it wTas wiser, in all cases, to apply to the muscle the 
stimulus of electricity rather than to leave it to itself. 
M. Duchenne informed Dr. W. W. Keen, in 1865, that 
he had changed his former views in regard to this 
matter; and my own later experience has more and more 
convinced me that the practice here advised is correct. I 
now direct the use of faradaic or galvanic currents from 
the earliest date at which the healing of the wound allows 
of their use, while with them I combine daily massage or 
deep kneading, and alternate hot and cold douches. The 
mode of using these means will presently be more ex- 
actly described. The general result which I hope to 
attain is the nutritive activity which electricity sustains, 
* Six days, Landry ; four to five days, Duchenne de Boulogne. 246 
‘ INJURIES OF NERVES. 
and the continuance of a larger supply of blood to the 
inert tissues than would enter them if they were not in- 
cessantly stimulated and subjected to those alterations of 
temperature, rest, and motion which belong to the normal 
state of limbs. When once the nerve is repaired, it finds 
the muscles in a far better condition to profit by this than 
could otherwise have been the case. Electricity, in some 
form, manipulation, and alternate hot and cold douches 
are, therefore, the three means which I most rely upon to 
relieve atrophy and muscular paralysis. 
Electricity.—It would be out of place to attempt to give 
here full directions as to the use of electricity, but it is 
necessary to offer such partial hints as may suffice to 
guide the physician called upon to treat the consequences 
of traumatic nerve lesions. 
The number of sittings need not exceed one every 
other day, and when the physician cannot himself give 
the time, it is quite possible to instruct an intelligent 
attendant, so as after awhile to confide to such hands a 
large share of these repeated applications, being careful 
to impress upon the patient the necessity of using a less 
powerful current as the case improves. From fifteen to 
thirty minutes are required on each occasion, and a cer- 
tain method should be followed, no matter what form of 
electricity be used. 
In hospital practice, or where the physician has control 
both of galvanic batteries and the induced current, the 
question as to their relative utility in traumatic palsies 
may present itself. As regards this, there is but one dis- 
tinct practical rule. Whatever form of current will best 
act on the muscles is the one to be made use of. 
The interrupted or rapidly reversed galvanic current, 
from ten to forty cells, will frequently excite the muscle 
when induction currents have lost their power, so that 
late in bad cases galvanism is usually to be preferred. TREATMENT. 
247 
It is common to find, after a time, that the muscle thus 
treated becomes sensitive to a strong induced current, 
which, for convenience, may be resorted to in order to 
complete the cure. Whatever current is the readiest 
exeitor is the one to be preferred, and galvanism in trau- 
matic, as in infantile palsies, is active where induced cur- 
rents fail us. It is, however, very largely a question of 
time and patience. Muscles which seem only capable of 
response to galvanism, will more slowly but surely amend 
under the use of a good primary current. 
This is fortunate, because few persons at present resort 
to galvanism, while induction batteries are within every 
one’s reach. In using these, I prefer the primary current 
as least painful and most efficient; but none of the com- 
mon machines for sale in this country have a sufficiently 
powerful primary current. 
Whatever be the form of electricity we employ, it is 
advisable to lessen the power as the muscles regain their 
excitability, and it is to be remembered that in traumatic 
palsy nothing is more common than to see a muscle 
restored to volitional control, long before it is able to 
contract at all under the use of faradaic currents. 
With either induced currents or galvanism, metallic or 
carbon conductors covered with chamois-skin or Canton 
flannel are to be used; and it is not only desirable to 
keep them well soaked with warm salt-water, but also, 
when the integuments are dry, as in winter, to soak the 
part itself previously, so as to lessen the resistance of the 
skin. 
If in the preliminary examination, the induced current 
be found competent to move the affected muscles, this 
alone may be employed, the two conductors being carried 
in turn over every enfeebled muscle,—one pole being 
left, in each case, over the point at which the muscle 
nerve enters it. Since even in the induced to-and-fro 248 
INJURIES OF NERVES. 
current, one pole is always more positive than the other, 
for reasons which I need not explain, it is found that 
rapid reversals of the poles by a current-changer greatly 
increase the effect. 
For galvanization, I employ a battery of sixty cells,* or 
Stohrer’s instrument of forty cells. The two conductors 
are at first placed, the one on the main nerve, the other on 
the affected muscle. The circuit is then completed, and 
the current made and broken at intervals not too short, 
or, for more powerful influence, the pole-changer is used 
by an assistant, so as to reverse the direction of the cur- 
rent from moment to moment. After a time the skin 
reddens intensely, making conduction easier, and the 
muscle, beginning to move, responds better and better. 
If, after a minute or two, there is no motion, the assistant 
adds pair by pair additional cells, until the muscle acts 
or the application grows too painful. When that amount 
of battery power is reached which is needed to move the 
muscle, it is generally found that during the remainder 
of the sitting the muscle will respond readily to a smaller 
number of cells than were at first needed to awaken its 
motility. 
If the muscle fails to reply to galvanism or the induc- 
tion coil after three or four sittings, the case is surely a 
bad one; but even where we obtain a response to galvan- 
ism, although we may be allowed to hope for a cure, there 
is not always a certainty of it; and I can recall cases in 
which every muscle of a limb so responded, and yet in 
which no step was gained by toilsome months of galvanic 
and other treatment. Happily such instances are rare. 
It also happens, however, that in certain muscles which 
for a long time fail to respond at all to electricity, the 
persistent use of this means is competent in time to re- 
* Made by the Galvano-Faradic Company of New York. TREATMENT. 
249 
store functional health. Before commencing the treat- 
ment of such cases, I am always careful to measure the 
size of fhe limb, since a change in its bulk and warmth 
often precedes the return of irritability, and may lead us 
to a hopeful continuance of the treatment. 
It is, in many cases, advisable to interrupt the electric 
treatment for a month, after it has been continued for 
two or three months. When, during the treatment, 
neuralgia comes on, it is also requisite to pause for 
awhile, or to make the sittings less frequent, when the 
pain, which is far from an unfavorable sign, will disappear. 
In bad cases, I have been in the habit of heating the 
part before the sitting, and even of keeping it in hot 
water during the use of the conductors, since I have fre- 
quently observed that when a palsied part is well warmed 
it reacts much more readily to all forms of stimulus, 
whether volitional or electric. 
For faradising insensible surfaces, I use the ordinary 
Duehenne brush of very fine wires, carried lightly over 
the skin, which has been previously dried and dusted with 
flour,* while one wet conductor remains pressed on the 
surface an inch or two distant. For this purpose the 
secondary current is needed.f 
Manipulation.—For want of a better name I have here 
styled manipulation what is known as shampooing, rub- 
bing, massage, etc. Its value in the treatment of all 
forms of indeed, of some other palsies, 
is very great, and the results which I have seen obtained 
by practiced rubbers were certainly to be gained by no 
other equally rapid treatment. 
* Duehenne. 
f Until lately, we possessed no good batteries of American make. Those 
manufactured by the Galvano-Faradic Company of New York have 
amply supplied this want, and are in all respects equal, and in some ways 
superior, to any of the foreign instruments. 250 
INJURIES OF NERVES. 
At the United States Army Hospital, we carefully 
trained several clever sergeants to act as rubbers, and 
some of these men became extremely expert. For suc- 
cess, the manipulator must be not only tender and gentle, 
but also strong and enduring, because a treatment by 
massage extending over an hour, as it should do, will 
severely task the strength of most men. 
If only the skin is to be acted on or excited, the operator 
should pinch lightly every part of the surface, and move 
it to and fro over the subjacent parts. The most intense 
reddening may be brought about in this manner. 
When the limb is wasted, and there is general slug- 
gishness or loss of function, the skin may first be treated 
by gently pinching and tapping it; then the joints are 
to be moved in turn, and lastly the muscles acted upon 
by firmly but gently kneading, rolling, and working 
them,—gradually increasing the power employed. I pre- 
fer also that every sitting should be preceded by a local 
hot bath. 
At the close of the manipulation, if it has lasted a 
half-hour or an hour, the limb becomes warm or even 
hot, the temperature rising by thermometric determina- 
tion one or two degrees F.* The skin under this usage 
seems to become thinner, more pliable, and less bound 
down to the parts beneath it, while the increase of tone 
in every muscle at all capable of response is most remark- 
able. 
I have several times noticed that muscles which were 
previously sluggish, after being thoroughly kneaded would 
contract far more readily when faradised. 
The general result seems to show that there is also a 
reflex influence exerted on the centres, because excessive 
kneading will sometimes, like induction currents, cause 
* In infantile and traumatic palsy. TREATMENT. 
251 
lumbar pain and cephalalgia, or nausea, and possibly 
great exhaustion ; but when the remedy has not been 
overused, the patient feels refreshed, and is sure to sleep 
the better for the process. 
For atrophy and muscular palsy, a treatment by elec- 
tricity three or four times a week, by daily massage, with 
local hot baths to precede each sitting, seems to me to 
fulfill all the needed indications. 
Strychnia.—In old cases, I see a good physiological rea- 
son for giving strychnia also, because it is probable that 
when a group of spinal ganglia has been long unused, 
it may need the special increase of irritability which this 
potent agent produces. 
I have many times employed strychnia by hypodermic 
injections into the limb, but as yet I have had none of the 
brilliant results which a few observers have obtained, nor 
can I conceive of any physiological grounds upon which 
we might reasonably hope for a greater utility from injec- 
tions into the palsied part than from those made else- 
where. 
Deformities from changes in the muscles.—While we are 
thus wisely using every means of keeping up the organic 
life of the limb, in a large number of cases, and despite our 
efforts, changes affecting mobility are taking place which 
I have elsewhere fully described. The muscles which re- 
main healthy being no longer compensated by their 
antagonists, gradually stretch these until they cause some 
deformity, which alters the forms of the articulations, and 
is productive of the most permanent mischief when the 
joints are at the same time suffering from the inflamma- 
tions so common in neural injuries. 
A still more troublesome cause of shortening in mus- 
cles is the organic shrinking which takes place, either 
with or after atrophy. This occasionally counterbalances 
the precedent shortening which has been due to the 252 
INJURIES OF NERVES. 
healthy tone of uninjured muscles, but in the end the lat- 
ter yield to the diseased groups, and in turn suffer elonga- 
tion. The power with which atrophic contractions act is 
enormous, and reminds us of the relentless shrinking of 
cicatrices. It overcomes the healthy muscles, distorts 
the members and subluxates the joints so as to place 
the most serious difficulties in the way of cure. The 
following case is a good illustration of these disastrous 
results, which, however, vary endlessly according to the 
part involved: 
Case 42.*—Gunshot wound of left arm ; injury of the ulnar 
and median nerves ; paralysis of motion, slight of sensation ; 
contraction of flexors; relaxation under treatment; atrophy; 
claw-hand from paralysis of interossei; stinging pain in hand ; 
great gain; interosseal paralysis alone remains; discharge 
with prothetic apparatus. Henry Gervaise, aged twenty, 
Canadian, blacksmith, enlisted February, 1862, in Com- 
pany F, 1st Vermont Cavalry. Healthy until shot, July 
7th, 1863, in the left arm. Probably the wound of entry 
was the one over the artery, at the edge of the biceps, 
six inches above the internal condyle of the humerus. 
Exit on postero-internal face of arm, half an inch above 
and three and a quarter inches behind the other wound. 
He felt pain in the arm, but dismounted, the artery 
jetting blood. After walking a little way he fainted, 
and awakening after some hours, found that the bleeding 
had ceased, but that he had no motion from the shoulder 
to the tinger-tips and that sensation was lessened below 
the elbow. The pain in the hand grew worse gradually, 
and was neuralgic in character. On the second day he 
ftMild move the elbow, and during the first week could 
the thumb. About December, 1863, he began to 
* Mitchell, Morehouse, and Keen, op. cit. TREATMENT. 
253 
move the fingers voluntarily, and this control has con- 
tinued to improve. 
In January, 1864, electricity was used in the hospital 
where he then was, but he says it was applied only on 
the fingers. 
Condition on entering the U. S. A. Hospital for Injuries 
and Diseases of the Hervous System, February 18,1864.— 
Hand congested; palm purplish; nails curved. Measure- 
ments: biceps, right, eleven and three-eighths inches; 
left, ten and one-eighth; forearm, right, eleven and one- 
half inches; left, ten. 
Flexors in forearm wasted considerably; thumb mus- 
cles wasted, and all the interossei much atrophied. Ho 
stiffness in the joints. The short flexor of the thumb 
and the flexor group in the forearm are moderately con- 
tracted. The former defect has allowed the extensors 
of the thumb to act on it so as to bring its metacarpal 
bone level with those of the fingers, and to turn the nail 
upward. 
Sensation.—Ansesthesia and analgesia in palm and palmar 
face of all the fingers, but only in the dorsum of the hand, 
and not on the dorsal aspect of the fingers. 
Motion.—Good above elbow. Supination and pronation 
normal. The wrist flexion is incomplete, from want of 
power. Extension limited by flexor contraction. 
Thumb.—Flexion partly lost from want of power, and 
extension limited by contraction of short flexor. He has 
no abduction or adduction of the fingers, and cannot 
flex the first phalanges or extend the last two. 
It is not necessary to speak in detail as to the electric 
properties, which were wholly absent in the interossJB 
muscles, and defective in some others. ▼ 
Treatment.—Electricity,douches; splint to correct flex- 
ions. Under this treatment, with energetic use of passive 
motion, the flexions were corrected, and every motion re- 254 
INJURIES OP NERVES. 
gained, except that of the interosseal muscles. To have 
a prothetic apparatus, and be discharged. 
Re-examined April 9, 1864.—The hand is now healthy 
in color, the neuralgia nearly entirely well. 
April 22,1867. Visible condition of hands.—Rails of the 
left hand slightly incurvated; palm mottled, almost 
normal. 
Measurements.—Biceps: right, ten and three-eighths 
inches; left, ten and one-eighth. Forearm: right, ten and 
five-eighths; left, ten and a quarter. The loss in the right 
arm is probably due to a change in his occupation, he 
being now a stationer. The left arm has gained relatively. 
Nutrition.—Flexors of left forearm,'thumb muscles, and 
interossei all slightly wasted. Flexors of fingers the only 
contracted muscles. Thumb has very nearly regained its 
normal position. 
Sensation normal on dorsum of hand, perfectly localized, 
but a little blunted on palm; dull and rather imperfectly 
localized on palmar surface of fingers. 
Motion.—Flexion and extension of wrist natural when 
the fingers are flexed, as they always are except when 
passively extended. Extension is limited by the con- 
tracted finger flexors. Pronation and supination entire. 
Abduction of thumb lost; flexion weak; extension good. 
Ro abduction or adduction of fingers; no extension of 
last two phalanges, save through violent extension of the 
first phalanx; but there is some flexion of the first. It 
is doubtful whether this flexion is not merely a secondary 
effect of the flexion of the last two phalanges. The claw- 
hand is only manifest on extension of the fingers, the 
ijpst phalanges alone being extended, the last two flexed 
one-half. 
Electrical test.—Electro-muscular sensibility in left arm 
and forearm the same as in the right; in the hand, dimin- 
ished nearly one-half. Electro-muscular contractility is not TREATMENT. 
255 
now absent in a single muscle. In the left arm and forearm 
it is very slightly, if at all diminished. In the left hand 
all the muscles respond, the general loss being about one- 
half; but in the first and fourth dorsal interosseal, about 
three-quarters or more.* 
Temperature (the thermometer being placed in the 
metacarpo-phalangeal fold, where both hands could close 
on it about equally well), after being tested for half an 
hour in each hand, was, right, 95|°; left, 96° Fahr. 
I have alluded to the fact that the temperature in 
parts partially paralyzed by wounds was in some cases 
higher than upon the healthy side. This was especi- 
ally noticeable in the instances of causalgia described 
by my colleagues and myself. As the facts here referred 
to had excited some little doubt, I lately examined in the 
case of Schiveleyf the thermal condition three years after 
he left the hospital. To my surprise I found that, despite 
the great changes made by time, the temperature of the 
injured hand was still slightly higher than that of the 
other member. Schiveley had severe burning pain. Ger- 
vaise, the patient last described, suffered only from neu- 
ralgia of the ordinary type. 
In this man, the flexors of the hand were wasted as well 
as the muscles of the thumb and the interosseal group. 
The short flexor of the thumb, and the flexor mass in the 
forearm, were moderately contracted. The former defect 
allowed the thumb extensors “ to act on it, so as to bring 
its metacarpus level with those of the palm, and to turn 
the nail upward so that it lay in the same plane with the 
fingers.” There was, therefore, palsy of the interossei, 
and in consequence a condition which made the hand 
* By means of the battery he can make a good fist, being able to bring 
the thumb into perfect apposition with the fingers. 
f Gunshot Wounds and other Injuries of Nerves.—Case. 256 
INJURIES OF NERVES. 
look precisely like that of a monkey, and which also 
resulted in the curious deformity described by Duchenne, 
and which came to be known in our hospital as the “claw- 
hand.” It is due to these facts: the interossei being 
palsied, the extension of the second and third phalanges 
and the flexion of the first are lost as independent acts. 
But the two common flexors bend the second and third 
joints, and being without antagonists, roll them into the 
palm ; while the common extensor, which only acts on 
the first phalanges, having also lost its opponent, per- 
manently extends these parts, and thus produces the claw- 
hand I have described. 
When both sets of muscles have been attacked, we have 
very curious results. Thus in the case of Schiveley, the 
flexor carpi ulnaris, palmaris longus, and flexor carpi 
radialis being strongly contracted, the wrist was bent at a 
right angle and drawn to the ulnar side. The extensor 
group was also contracted, and the first phalanges, from 
being violently exteuded while the wrist was flexed, under- 
went subluxation. 
In rare instances I have seen the atrophy and shortening 
confined to small tracts of a muscle, as in one instance 
to the portion of the extensor communis digitorum which 
acts on the second finger. In cases of extreme general 
atrophy of a whole limb, it might be expected that the 
groups which in health preponderate would, in contract- 
ing, always overcome the rest. Yet this seems scarcely 
to be the case to an}7 marked extent, except in the hand. 
Certainly in the examples I have seen of general atrophy 
of the leg, the contractions did not usually result in 
marked deformities. Most commonly the knee has been 
slightly flexed and the foot extended, but the toes did not 
sutler such changes as fall on the fingers. 
I am now attending a case of palsy from the pressure 
of intra-spinal exostosis, in which the calf muscles have TREATMENT. 
257 
undergone atrophy and excessive contraction so as curi- 
ously to distort the foot. As a rule, in the arm it is palsy 
of the flexors which brings about these conditions. "When 
the more feeble extensors are thus affected, the greater 
mass and power of the flexors seem usually able to resist 
better the force of contraction. 
Prothetic apparatus.—We have no early means of pre- 
venting these alterations, except by the use of prothetic 
apparatus, the varieties of which I do not propose to de- 
scribe, since they either are well known or need to be so 
modified for every new case as to baffle all description. 
Their object is solely to strengthen in the one case the 
palsied group, and in the other to aid the normal muscles 
in resisting the shortening of atrophied fibres. 
Final relief is to be looked for from the use of elec- 
tricity, rubbing, baths, and time; but if these fail us, as 
they must sometimes do, and the limb continues to alter 
in form, it is often possible bj cutting tendons and restor- 
ing parts to their places, by the aid of apparatus, to leave 
to the sufferer a limb which, in the case of the leg, 
may be far better than an artificial member, and in 
the case of the arm will be more or less valuable ac- 
cording to the muscles which remain in service, and, 
above all, the amount of joint disease which limits their 
usefulness. 
Treatment of spasm.—Persistent spasms of muscles from 
neural injuries are rare. In the case of Monaghan, already 
described, it was necessary to divide several tendons on 
this account, after which extension on a splint resulted in 
recovery. 
I have several times seen this form of spasm, owing 
to rheumatic causes, affecting the nerves. In one of these 
cases the patient suffered from intense pain in the right 
arm, from some loss of power in the shoulder muscles, 
and from spasm of the short flexor of the thumb. 258 
INJURIES OF NERVES. 
We used injections of atropia, which were thrown into the 
mass of the muscle itself. At first this caused increased 
contraction, but within a few minutes entire relaxation 
ensued. The muscle never again acted as powerfully, and 
successive injections at intervals of a day or two brought 
about a cure. 
The same means were used with equal good fortune in 
a case of spasm of the abductor minimi digiti, but unfor- 
tunately the notes of this case are lost, so that I am unable 
to state either the cause of the spasm or the details of its 
recovery. In longer muscles, such as the flexor carpi 
ulnaris, this treatment usually failed us. In at least two 
cases, however, which I have seen since then, the happiest 
results followed its use in spasm of unknown origin in 
the right trapezius muscle, and also in spastic contraction 
of the biceps. 
I have many times endeavored to relieve these contrac- 
tions, and those which succeed some cases of cerebral 
apoplexy, by faradising their opponents. Unlike Du- 
chenne, I have had unvarying ill success, chiefly because 
the currents excite reflectively the contracted muscles, 
and this was also the uniform report in all such efforts 
made at the U. S. A. Hospital for Nervous Diseases, etc.* 
Treatment of joint disease.—The most mischievous of all 
the consequences of nerve injuries, of all of them the 
most fertile in direct and indirect evil, are certainly the 
joint inflammations. A case may be doing perfectly well, 
when suddenly or slowly one joint after another becomes 
swollen, stiff’, and painful. When this happens, the mem- 
bers remain, as it were, set in the false positions into 
which contractions, palsies, or atrophic shortenings have 
dragged them. Exercise becomes impossible, from the 
* Even when some relaxation has seemed to he caused by long electri- 
zation, there has been really no gain of the least practical value. TREATMENT. 
259 
pain it causes, and passive motions and electricity must 
for the same reason be laid aside. 
Often, indeed, the pain from these joints is exquisite, 
and in the first few months of treatment defies all means 
of relief except absolute repose; and this, unhappily, is 
a fatal sentence for the limb. When left to themselves, 
adhesions are sure to form, and partial anchyloses occur, 
so that it proved best on the whole to treat them for a 
time with small blisters, and as early as the inflammations 
allowed, to anaesthetize the patient and use passive motion 
with freedom. This, at all events, was the method found 
most productive of good after gunshot injuries of nerves; 
and in the rare cases of arthritic trouble from nerve 
wounds which I have since seen, I have found it the only 
reliable treatment. 
Where the joint maladies are of long standing and ne- 
glected, the induced current, or, still better, that from a 
galvanic battery, should be used, and the adhesions at 
once broken up under ether or chloroform, the sufferer 
being fortunate if the state of the muscles has been such 
as not to alter materially the normal relations of the 
articular surfaces. 
After a year or two has passed, leaving the smaller joints 
enlarged and only slightly painful, they may be slowly 
reduced by surrounding them with rings of caoutchouc 
cut from thin rubber tubes and slipped over the joint. 
The pressure is borne very well for the day or night, and 
is pretty sure, in time, to lessen the size of the part most 
remarkably, while at this stage the persevering use of gal- 
vanism, of passive motion, and of all the forms of rub- 
bing, becomes available. 
Notwithstanding the obstinacy of these arthritic troubles, 
it is sometimes possible to overcome them when the pa- 
tient is sufficiently determined; or if, as in the following 
example, the resolute rule of a military hospital can be 260 
INJURIES OF NERVES. 
called upon to replace the enfeebled will of the sufferer. 
In other respects this case is remarkable, since it shows 
that a lesion probably limited to the anterior columns of 
the spine in the neck, may occasion atrophy and almost 
universal anchylosis from arthritic lesions. Its impor- 
tance must excuse my quoting at length from the little 
volume so often mentioned.* 
Case 43.—S. Johnson, aged eighteen, Pennsylvania. Ho 
previous business. Private, Company I, 8th Pennsylva- 
nia Cavalry. Enlisted for three years, August, 1861. 
Health good previous to enlistment, except as interrupted 
by an attack of typhoid fever four years before. Six 
months after enlisting he had a fever, probably of a ma- 
larious character. Three weeks before he was wounded 
he suffered with pain in the right leg, made worse by 
movement, but unaccompanied by any rheumatic swell- 
ing of the joints. 
May 8, 1863.—He was wounded by a small ball in the 
left cheek while riding at a trot. It entered at the mid- 
dle of the ramus of the jaw, a little below the level of the 
teeth. From his position, as well as the after-evidence, it 
seems that the ball passed backward and inward, and 
finally lodged in the spinal column. The edge of the jaw 
was somewhat injured, and probably was the source of 
the small fragments of bone which afterwards escaped 
from the neck. When shot, the man fell forward on his 
horse’s neck; says he was confused, though conscious, 
and felt as if he had been struck in the ear, and then 
lifted up in air. He also felt instant pain in the back of 
his neck, and in all of his limbs. There were no spasms. 
He was removed from his horse and carried to a house 
near by. The motion increased his pain, especially any 
movement of the neck. He now became aware of the 
* Op. cit. p. 22, Injuries of Nerves, etc. TREATMENT. 
261 
total motor paralysis of the arms and legs. He is not 
sure whether sensibility was also extinct. Two days after 
being wounded, he became delirious, but gradually recov- 
ered his senses after three or four days. lie was finally 
sent to the Douglas Hospital, Washington, then under 
the charge of Assistant Surgeon Thomson, U. S. A., and 
was transferred to our own wards July 19, 1863. 
The wound healed in nine weeks after the discharge of 
a few small fragments of the jaw. Meanwhile his left leg 
improved slightly. 
His case is thus described on his entrance to our wards. 
A more wretched spectacle than this man presents can 
hardly be imagined. He lies in bed, motionless, ema- 
ciated to the last degree, and with bed-sores on both 
elbows and both hips. His hands lie crossed on his chest, 
perfectly rigid ; the fingers extended; the skin congested 
and thin;.the nails curved; false anchylosis of all the 
joints of the upper limbs; the head and neck rigid, 
with acute pain in these parts on movement. The right 
leg has motion of a feeble nature in all of the joints; 
the left only very slight voluntary movement. The 
hands, the appearance of which has been already alluded 
to, present certain characteristics which belong usually to 
cases in which there have been wounds of the brachial 
nerves. In the present instance, as in many others, these 
peculiarities have been modified by the long-continued 
rest of the limbs in one posture. The results of the nerve 
injury and its consequent effects on the nutrition of the 
part may, however, be partially discriminated, so that 
what is due to them and what is due to mere rest may be 
discerned to some extent. Thus, the shining palm, the 
slight eczema, the burning pain, the atrophy, and the 
swollen joints, whose appearance simulates subacute 
rheumatism, with the contractions of certain muscles, 
are all owing to the nerve lesion ; while the anchylosis 262 
INJURIES OF NERVES. 
and the peculiar flattening of the hand are perhaps owing 
to this and to the long rest and disuse, the arms mean- 
while lying crossed on the chest, the Augers in extension. 
Disuse alone might have caused some stiffness, but never 
to such a degree as occurs when the joints have been sub- 
acutely inflamed at the same time. The loss of the lat- 
eral palmar arch is owing to both causes, and the monkey- 
like appearance of the hand, the thumb rotated outward, 
and its nail looking upward and even toward the fore- 
finger, is caused, first, by the subluxation of the metacarpo- 
phalangeal articulation, and secondly, by the weakening 
and atrophy of the adductor and short flexors of the 
thumb. The nerve lesion, affecting the muscles and the 
general nutrition of the part, has so relaxed the unused 
tissues of the limb as to make the pressure of its own 
weight effective in thus altering its form. 
Sensation.—Tactile sense enfeebled equally in both arms, 
worse in the left. Feeble in both legs, worse in the left. 
Confused power of localizing sensation in the legs. Mis- 
takes right for left, but not left for right. 
There is muscular hypersesthesia of the upper members, 
shoulders and neck; none in the legs. The left brachial 
plexus is sensitive to pressure, and this causes pain in the 
left arm and hand. The palms tingle, and burn a little, 
the feet not at all. 
Every attempt at passive motion causes exquisite pain 
in the arms, hands, and shoulders, but most of all in the 
back of the neck, about the first and second vertebrae. 
This is due, first, to the hypersesthesia of the muscles, and 
secondly, to the state of false anchylosis, owing to rest in 
one fixed posture. He either is too weak to move the 
body or is really paralyzed in the spinal muscles. The 
biceps, flexors, and wrist muscles are very rigid, as well 
as the trapezius, and the atrophy of the muscles through- 
out the upper limbs is singularly well marked. TREATMENT. 
263 
His condition was too grave to allow of an electric ex- 
amination. 
There was no inflammatory swelling about the neck, 
and it was, therefore, resolved to treat him with free pas- 
sive motion, breaking the adhesions and forcing him to 
exert himself as far as he could. Tonics, porter, and lib- 
eral diet were ordered, and the shampooing and passive 
movement were vigorously carried out, despite his pain 
and most earnest supplications to be let alone. 
The bed-sores were treated with alternate applications 
of iced-water for ten minutes, followed by a flaxseed-meal 
poultice as hot as could be borne.' This local means, 
recommended by Brown-Sequard, succeeded marvelously, 
as it always does, the bed-sores healing easily within ten 
days. 
August 25th.—He is still losing flesh. There is great 
pain in the neck. Moves his head and legs a little better. 
ISTo change in the arms. Despite his prayers and protes- 
tations, the shampooing was continued; and on October 
15th, he was greatly improved. He is fatter; the legs 
can be voluntarily crossed; appetite voracious. 
December 7th.—Great gain. Can move right arm freely. 
Can raise his head ; bend and turn the neck. Sits up daily. 
December 29th.—Motion returning in right hand. No 
gain in left, but in both the malpositions have been 
relieved, and the hypersesthesia reduced. From this time 
the improvement was manifest and rapid. On January 
7 th, 1864, the case was carefully reviewed with the fol- 
lowing results: 
Nutrition.—Much fatter; atrophy lessened. The hands 
have lost their smooth, shining look, so expressive to us 
of a nerve lesion. The nails are less curved. The tem- 
perature is better. 
Sensation.—Right arm and hand. Tactility and localiz- 
ing sense good. Left arm rather less perfect. Tactility 264 
INJURIES OF NERVES. 
and localizing sense in legs normal, or nearly so. Sense 
of pain more perfect than at first, but even now a pinch 
causes a feeling of pricking only, rather than the usual 
sensation. There has been some burning of the right 
face, neck, and arm within the past week. 
Voluntary motion.—Left leg normal in extent of action, 
but still feeble. Right leg healthy. The right arm has 
regained all the shoulder and elbow motions, except that, 
owing to a remnant of contraction in the biceps, exten- 
sion is not quite entire. Flexion, pronation, and supina- 
tion are perfect. Extension of wrist incomplete, owing 
to contracted state of flexors. Flexion of wrist perfect. 
The thumb has lost abduction, owing to contraction of 
the adductor. Fingers, extension normal. The joints 
being still stiff and swollen, the second and third joints 
possess but two-thirds of their healthy extent of flexion. 
Left arm.—For ten days past the shoulder has begun 
to exhibit voluntary power. Elbow, no movement. Pro- 
nation and supination slight. Flexion and extension 
of wrist also slight. Fingers, feeble, tremulous move- 
ments. 
For the first time we now examined the electric state 
of the muscles. The electro-muscular contractility was 
good in the right biceps, feeble in the left. Good in the 
right supinator longus, feeble in the left. Good in the 
extensors of both hands. Good in the flexors of the right 
hand, feeble in the left. The interossei on both sides 
showed great loss of this property. The abductor pollicis 
on the left had no electro-muscular contractility. As a 
rule, this property was lessened in the left arm and 
shoulder, while the electro-muscular sensibility was 
scarcely altered in the two members, except, perhaps, 
some diminution in the thumb muscles of the left hand, 
and in the flexor group of the left forearm. The whole 
left arm was still very stiff. TREATMENT. 
265 
Ordered the patient to be etherized every day, and the 
adhesions to be forcibly broken. Passive motion to be 
continued, and the limbs to be faradised daily. 
The future progress was inconceivably rapid. 
On January 20th, he could rise to his feet, and by Feb- 
ruary 20th, could walk a few steps. March 20th, walks 
well without a cane or any aid; the left hand alone has not 
gained to any great extent, although the malposition 
has been much relieved. The patient was discharged 
in March, slightly shuffling in his walk, but with nearly 
entire use of all his limbs, except the left hand and 
forearm. 
Treatment of lesions of sensation; anaesthesia.—As with 
motion, so with sensation, we shall often find that tracts 
of skin which soon after the wounding are devoid of feel- 
ing, recover function within a few days. Where, how- 
ever, time enough has elapsed for nerve repair, and 
sensation is still lessened or lost, we have but few means 
of treatment to which it is worth while to resort, beyond 
the general measures employed, to sustain in the limb its 
nutritive life. Faradisation of the dry skin is the most 
efficient method of relief. 
The batteries generally used are of insufficient strength 
when we desire to awaken sensation in parts apparently 
devoid of all feeling. With a strong induced secondary 
current the electric brush is the most violent of all the 
excitants of the skin which do not disorganize its struct- 
ures, and under its repeated use it is common to find 
sensation returning to regions which are deficient in 
every form of sensory life, so that after two or three 
sittings even far slighter impressions can be felt.* 
* The finer the wires the more severe is the stimulation. I have fre- 
quently improvised an excellent brush by fraying out the threads of a 
conducting cord which contains a number of fine wires. 266 
INJURIES OF NERVES. 
Counter-irritation.—Of the many counter-irritants which 
I have employed, the most useful are lotions of oil of tur- 
pentine, which may be applied cold or hot, as we need 
slight or severe irritation. When a rag, dipped in hot 
turpentine and covered with rubber or oiled silk, is laid 
on the skin, we get the most powerful stimulation which 
this agent affords. No agent affects more unequally dif- 
ferent persons, so that some care may be needed in using 
it. I have known it to produce for hours the most unbear- 
able pain, while some patients seem scarcely to feel it at 
all. I do not know why we gain by using an irritant 
over very large surfaces, extending far beyond the region 
involved; but advantage certainly seems to arise from it. 
I recall, in this connection, the case of a soldier, whose 
whole arm was insensible from a fall on tbe shoulder. 
He suddenly recovered full feeling after the entire limb 
and back had been severely blistered by exposure to the 
sun. In injuries of nerves we rarely see sensation fully 
and perfectly restored; and for a long time, even in the 
best cases, the power to localize touch is more or less 
defective. 
Treatment of pain, neuralgia, causalgia.<—Neuralgic pain 
from nerve injury may depend upon pressure or the pres- 
ence of foreign bodies, and, if such causal relations can be 
made out, its relief, of course, becomes in some cases easy; 
but in general we shall have only to settle the question of 
whether the nerve be inflamed or in a state of sclerosis; 
while, if neither of these states man be shown to exist, we 
have to fall back upon the pathological phantom which 
we call irritation, and are driven then, and indeed very 
often, in every case, to treat the pain alone, without true 
knowledge of its immediate cause. 
The treatment of the pain from acutely-inflamed nerves 
is simply that of inflammation, which has already been 
described in full. TREATMENT. 
With a history of wound or blow, and that of inflam- 
mation, subsiding to a subacute stage, or never rising to 
an acute grade, we fall within a larger class of cases. 
The pain which comes from such pathological states is 
very varied in type; but so long as the nerve was tender 
it was our custom, in the U. S. A. Hospital, to resort to 
repeated leeching, which proved the most potent remedy. 
Since the war, I have frequently used dry cold, in any 
case of violent pain with steady local tenderness of the 
nerve. Employed for a week or two, it is sure to be of ser- 
vice, and, under its use, the nerves lose their irritability 
and distinctly shrink in size; but, to make this method 
most available, it must be kept up unfailingly both day and 
night. The certainty with which dry cold will break up 
the tendency of these cases to intermit, is most remark- 
able. I have under my charge at present a manufacturer 
of plumbers’ materials, who has for three years suffered 
intensely from neuritis of the left sciatic nerve, with con- 
stant increase of the pain at two o’clock every morning. 
The speed with which this habit broke up, and the neural 
tenderness lessened under the use of ice, was most satisfac- 
tory. When dry cold cannot be applied, I resort to moist 
heat, in the form of poultices, in which the whole limb 
should be wrapped, the heat of these applications being sus- 
tained by the aid of salt- or sand-bags, placed on their 
outside. 
A variety of local remedies have found more or less 
favor in the treatment of traumatic neuralgia, whether 
related plainly or not to inflammatory causes. The3r 
passed successively under trial in our vast experience 
during the war. For the most part they may be classed 
with the therapeutics of despair, the use of narcotic injec- 
tions having allowed us to dispense with them altogether. 
Counter-irritation.—The use of irritants over the cicatrix 
or the nerve track we found but rarely of value, and they INJURIES OF NERVES. 
were sometimes most distinctly hurtful. In a few in- 
stances I have followed Pearson’s counsel, in irritating the 
whole skin of the member, and have occasionally found 
the plan serviceable.* Yeratria, so available in common 
neuralgias, I do not. employ in cases arising from in- 
juries, nor has the local use of chloroform been of more 
than temporary benefit. Aconite, the most powerful of all 
the local agents, I used with good effect in the only case 
of neuralgia from wound of a small sensory nerve of the 
skin which I have lately seen ; hut it is a drug the employ- 
ment of which demands extreme caution, not less on 
account of its great power to depress the heart, than 
because of the mode in which it sometimes acts locally. 
I saw, several years ago, a gentleman who had received 
a blow on the supra-orbital region, which was followed by 
severe neuralgia, assuming a quotidian type, and for 
which the tr. aconit. fort, had been very freely used as a 
local measure. The space covered by it soon began to tingle 
and burn severely, and continued to do so for several 
weeks, although the sense of touch in the affected region 
was absolutely abolished. In another instance I employed 
it to relieve the pain which followed an injury of my own 
thumb. Within an hour it caused the most severe tin- 
gling, which soon attacked the skin of the whole body, 
and for many days I was eased only by dressing lightly 
and exposing myself to the cold January air. The effects 
lasted for a week. 
Acupuncturation.—Of acupuncture in traumatic neural- 
gia, I have nothing good to say; it was repeatedly used 
by our staff, without the slightest advantage. 
Hypodermic injections, narcotics.—The pains of traumatic 
neuralgia are so terrible that we are usually driven at 
once to the use of narcotic hypodermic injections, without 
which it would often be impossible to relieve such cases. 
* See p. 233. TREATMENT. 
269 
In neuralgia, from what we call, for want of a better 
term, irritation of nerves, there is reason to believe that 
some of the opiates in the form of hypodermic injection, 
may prove more or less curative in their action; but where, 
as in most traumatic neuralgias, there is manifest organic 
alteration of the nerve, such agents are chiefly of service 
because they relieve pain, and thus enable us to bridge 
over, so to speak, the many months of torture which are 
needed to bring the nerve back to health again, or to 
afiord time for electrical or other treatment. Without 
some such heroic means of dulling pain, few men would 
be contented to await in patient agony the long months 
which must often pass away before relief may come, 
if it come at all. This method therefore lias, within my 
own knowledge, been the saving of a number of nerves 
and of many limbs which otherwise must have been sac- 
rificed for the purpose of relieving unendurable pain. 
At the present time this mode of using narcotics has 
grown into common use, but even yet it is scarcely esti- 
mated at its full value. In the wards for nerve wounds in 
the U. S. A. Hospital it was almost the only plan of treat- 
ing severe neuralgic pain, so that twice or thrice a day the 
resident surgeons passed around these wards with their 
narcotics and hypodermic syringes, seeing, as a physician 
observed to me, anguish and troubled faces before them, 
and leaving behind them comfort, and even smiles. The 
picture is not overdrawn, since, perhaps, few hospitals have 
ever embraced at one time so many cases of horrible tor- 
ture. It was usual at one period, I believe, for the assist- 
ants to give every morning and every night between sixty 
and eighty hypodermic injections. 
During one year at least forty thousand doses of various 
narcotics were thus administered without an accident, and 
in certain single cases upwards of five hundred hypoder- 
mic injections were used, so that if there were no other 270 
INJURIES OF NERVES. 
evidence of the innocence of this mode of medication, 
our own experience would have been amply competent 
to settle the question. 
I have had large opportunity for studying in traumatic 
neuralgia the comparative merits of narcotics used by the 
mouth or under the skin, and I have no hesitation in 
stating as my opinion, that the latter method is not only 
the more effective, but also the less harmful constitu- 
tionally. 
For the easing of neuro-traumatic pain we tried,* in turn, 
the whole range of medicines known as narcotics, such as 
conia, hyoscyamus, daturia, atropia, and morphia. None 
of them, save the last, seemed, when singly used, to be 
of the slightest value, and one by one they were laid 
aside until, in the vast mass of cases, the salts of morphia 
alone were employed. A careful series of examinations 
showed very distinctly the trifling influence of atropia 
upon this form of pain. Several cases of intense neural- 
gia from wounds were treated with injections of sulphate 
of morphia under the skin in rising doses. When we 
learned the amount needed to give entire ease, we used 
in its place, next day, a full dose of atropia, our largest 
injection having been one-fifteenth of a grain. The most 
absolute failure attended these efforts, so that without de- 
nying to this latter drug the power ascribed to it of re- 
lieving certain neuralgias, I am sure that it is in the 
traumatic species simply useless. 
The morphia salts, on the other hand, are invaluable. 
For h}7podermic use I usually employ at first one-fourth 
of a grain of the sulphate, but I have given as much as 
a grain and a half twice a day. When continuously used, 
it is very curious that its hypnotic manifestations lessen, 
while its power to abolish pain continues, so that the 
* Mitchell, Morehouse, and Keen, op. eit., 146. TREATMENT. 
271 
patient who receives a half-grain or more of morphia 
may become presently free from pain, and yet walk about 
with little or no desire to sleep. The ability to lessen 
pain is not therefore of necessity connected with the sleep- 
compelling potency. Where, however, the latter is in- 
conveniently felt, and wTe desire the former only, it is pos- 
sible to attain the end in view by using with the morphia 
a certain share of atropia. Thus, if we inject half a grain 
of sulphate of morphia, and with it the thirtieth of a 
grain of sulphate of atropia, the anaesthetic force of the 
morphia will rest unaltered, but the tendency to sleep 
will be greatly diminished. The views here set forth 
were reached after long and careful experiments on large 
numbers of men,* and seem to justify the practice of using 
atropia and morphia together. 
As regards the place of injection, I agree with most 
observers that it is generally of little moment, the effect 
being the same whether it be thrown into the affected 
limb or into a remote part. The single exception to this 
I shall presently mention. 
Manipulation.—I have elsewhere spoken of the use of 
massage in restoring the nutrition and motions of a limb. 
It is only of late that I have sought to control pain and 
alter the nutritive state of a diseased nerve trunk by this 
means. A case of contusion of the ulnar nerve became 
subject to intense neuralgia, the nerve being hardened 
and enlarged, owing, probably, to subacute neuritis. It 
was very tender, and no application of electricity was 
borne with any patience. The pain was relieved by 
hypodermic injections, but after using many remedies, 
* Antagonism of Atropia and Morphia, etc., S. Weir Mitchell, W. W. 
Keen, and G. E. Morehouse, Am. Journ. Med. Sci., July, 1865. These re- 
searches led us to the conclusion that the two drugs are mutually antag- 
onistic through a part only of their range of symptoms, even agreeing 
as to some of their modes of activity. 272 
INJURIES OF NERVES. 
and at last the actual cautery over the nerve trunk, with- 
out altering its size or tenderness. I patiently tried 
whether by slow and careful manipulations I could 
enable it to hear pressure. After a course of gentle fric- 
tion, lasting half an hour, I succeeded in my object, and 
three sittings enabled me to rub, and even knead quite 
roughly, the diseased part. I then taught the lad’s 
sister to execute the same manoeuvres, and was pleased 
to find that after some thirty sittings he could readily 
bear the use of ice, which before he could not endure, and 
that the nerve was plainly less in size and of diminished 
density. 
This very instructive case has taught me in other in- 
stances to help the progress of the nerve towards health 
by like means whenever there are tenderness aud sclero- 
tic conditions. I need not say that some tact is needed 
in slowly increasing the force of the friction and the depth 
of the pressure employed. Moreover, to be of value 
each sitting should last from half an hour to an hour. 
Any intelligent attendant can readily be taught the art 
of methodical rubbing, and for a nurse there is no more 
useful attainment. 
Causalgia or burning pain; water-dressings.—A vast num- 
ber of means were tried to ease or cure causalgia, but the 
one essential for comfort was the use of water-dressings, 
which were unceasingly renewed, the sufferers carrying 
a bottle of water and a sponge and keeping the part 
covered. I have never known a man affiicted with 
causalgia who did not learn very soon the use of this 
agent, and I never knew one who could be induced to 
exchange it for any other permanent dressing. 
Hypodermic injections.—Further relief was given by 
hypodermic injections of morphia, used twice a day and 
injected into the tissues of the affected part. I am aware 
that this is not in accordance with recent views as to TREATMENT. 
273 
the equal efficacy of injections at points remote from the 
seat of pain; but I am well satisfied that in causalgia 
something is gained by the local proximity. Numerous 
experiments were made to determine whether as full relief 
might not follow injections at distant points, but although 
the injecting of the burning hand produced in many cases 
torture, the patient was sure to insist upon it after a few 
trials of other localities. 
Symptoms of neuritis, where this was plainly the pain- 
cause, were met by the means already described; but the 
use of ice on the burning part was commonly too painful 
to be long endured. 
Blisters.—The curative treatment was simple. It con- 
sisted in blistering the burning part repeatedly with 
Granville’s lotion or cantharides. Nor was it necessary 
to merely blister until we lessened or destroyed the 
burning pain, since relapses were common ; and, to avoid 
these, the part required to be several times vesicated after 
an apparent cure had been effected. In light cases two 
or three blisters have answered; in others, ten or twelve 
have been needed, and, in very rare examples, this and 
every method failed us, although such was never the case 
in any instance which was treated early,—only the oldest 
cases being thus obstinate. The following history is a 
good illustration of the varieties of treatment essayed, 
and of the terrible nature of this most interesting symp- 
tom : 
Case 44.*—Gunshot wound of the left brachial plexus; pa- 
ralysis of motion and sensation; muscular hypersesthesia ; in- 
tense burning in hand and arm; nutritive changes ; atrophy; 
contracted extensors; relief; discharged. A. I). Marks, ser- 
geant Company C, 3d Maryland Volunteers, aged forty- 
three, enlisted August, 1861. Previously healthy. 
* Gunshot Wounds and other Injuries of Nerves, p. 148. 274 
INJURIES OF NERVES. 
May 3, 1863, at Chancellorsville, he received two 
wounds, one in the neck and one in the chest. The first 
ball passed in below the anterior boundary of the left arm- 
pit, through the margin of the great pectoral muscle, the 
arm being raised at the moment. The missile glanced on 
the neck of the humerus, and made its escape anterior to 
the coracoid process, apparently wounding the plexus. As 
he turned to leave the field, a second ball entered the right 
side of the back, to the right of the eighth dorsal vertebra, 
and, crossing behind the spine, entered the left side of the 
chest. The first wound caused palsy of motion and feeling 
in the left arm. The second gave rise to cough, spitting 
of blood, dysphagia, etc. It finally caused pleurisy, and 
large escape of pus during breathing. The wound is now 
closed, July 4, 1863, but the lower half of the lung is 
consolidated. The second wound brought him to the 
ground. He was taken prisoner, exposed a good deal to 
bad weather, and finally exchanged, and sent to Satterlee 
General Hospital, West Philadelphia, June 10, 1863. 
During the first week, the arm, though palsied, was 
painless. Then he began to feel a knifelike pain from 
the wound down the inside of the limb, and also on its 
front, and on the ulnar side, half-way to the wrist. With 
these pains came a tingling and burning sensation, as 
when the blood returns into a limb said to have been 
asleep. Soon afterwards this extended to the hand also, 
and he became able to feel the touch of foreign bodies. 
Present state, July 5, 1863.—He lies on his back, anx- 
ious-looking and pain-worn. The left arm rests on a 
pillow. It is cold, mottled, and swollen. The skin of the 
hand is thin, and dark-red, but presents no eruption. 
Tactility, nowhere absent, is dull on the dorsum of the 
hand and fingers. Except in these parts, localizing sen- 
sation is good. The whole arm and hand, except its back 
part, is, as he says, alive with burning pain, which warmth TREATMENT. 
275 
and dependence of the limb increase, and which cold and 
wetting ease considerably. It is subject to daily exacer- 
bations about mid-day. 
Motion.—The shoulder muscles act well. The deltoid 
is feeble. There is no motion below the elbow. The 
lingers are half flexed, and their joints swollen, sore, 
and congested. The deltoid is atrophied one-half. The 
extensors in the forearm are flabby, but the general 
oedema prevents us from telling whether the forearm 
muscles are wasted or not. Pressure on the cicatrix gives 
no pain. 
While at Satterlee Hospital, Dr. Walter P. Atlee used 
ice to the arm, and on the shoulder a blister, dressed with 
morphia. These measures relieved the arm for the time 
without aiding the hand. 
Ordered hypodermic injections of the fourth of a grain 
of sulphate of morphia, near the scar, twice a day. This 
relieved the arm; the hand growing daily worse, so that 
even ice ceased to afford ease, and he constantly prayed 
us to amputate the arm. 
July 7th.—Erysipelas set in about the seat of the injec- 
tions, and they were discontinued, for a time, morphia 
being used internally, and lead-water locally. 
On the 9th, the disease had left him, and two drops of 
conia were injected into the shoulder. This was thrice 
repeated, but gave no relief. Atropia, one-twenty-fifth of 
a grain, was next essayed, three times successively, at in- 
tervals of two hours. It caused dilatation of the pupils, 
flushed face, giddiness, and dry tongue. The only valua- 
ble result was a relaxation of the flexors of the fingers? 
which had become contracted, but which never afterwards 
became so rigid as they had been. The patient himself 
called attention to this singular effect. Again morphia, 
one-third of a grain, was injected into the arm without 
aiding the hand. 
O 276 
INJURIES OF NERVES. 
July 15th to July 20th.—Injections of morphia were 
made into the hand twice a day. They gave so much 
ease that the ice was temporarily abandoned. 
July 21st.—For the first time we were able to examine 
the limb with electricity. 
Tactile sensation was good in the arm, and absent in 
the ulnar distribution. In all other parts of the hand 
tactile sensation existed. In the portions insensitive to 
touch, deep pressure and pinching caused pain, which 
was very severe, but was indistinctly localized by the 
patient. 
Electro-muscular contractility was absent in the whole 
hand and forearm. The currents caused everywhere great 
pain, so that we could not tell if it were muscular or not. 
Probably the muscles still had sensation, since pressure 
on them was agonizing. Every electric examination 
necessitated the immediate use of morphia injections. 
August 14th.—The recent warm weather has increased 
the pain, so that he moans and weeps incessantly. 
Up to September 9th, various means were employed. 
The injections have been so numerous that the part is 
dotted with punctures, and their irritation has aggravated 
his sufferings to such a degree that they have been perma- 
nently laid aside for the internal use of narcotics. As local 
agents, we have had recourse to laudanum, lead-water, 
ice, oil, poultices with and without soda, and poultices of 
carbonate of soda, with vinegar to release carbonic acid. 
Of these the soda poultice did best; but in this, as in 
every instance, the ease lasted but for a day or two. In 
despair, leeches were placed about the cicatrix, and 
blisters were applied over it and kept open, and also 
over the nerves which were tender on pressure; neither 
aided him. 
Meanwhile the pain increased, but became limited to 
the palm and fingers, and lower forearm, with darting TREATMENT. 
277 
pains up tlie arm. The tactility improved and the mus- 
cular tenderness lessened. The general oedema disap- 
peared, and the atrophy was seen to be extreme, while 
the finger-joints remained sore and swollen. Every mo- 
tion or vibration caused pain. 
October 18th.—A blister on the palm failed to draw, 
but a blister on the dorsum of the hand acted well, 
and gave very marked relief. It was followed by am- 
monia blisters on the palm and arm. These were repeated, 
with, finally, cantharidal blisters. And now for the first 
time the ease was complete. Incessant blisters gradually 
ameliorated the pain. They were continued every few 
days for two months, until every trace of burning left 
him. He was so sure of the relief from this application, 
that he was unwilling to allow the hand to heal before 
using a new one. 
December 1st.—Slight pneumonia of right lung. 
December 10th.—Electricity ordered. Immediate re- 
turn of pain. Ceased its use. His arm and hand were 
shampooed daily, passive motion was employed, and he 
began to sit up and move about. 
January 6, 1864.—Careful re-examination. Arm gain- 
ing flesh. Cicatrix shrinking. Atrophy general. Worst 
in the extensor group, in the forearm. Sensation good 
throughout, but not quite perfect. 
Voluntary movements.—Shoulder abduction, one-third; 
other actions perfect. Elbow extension complete. Flexion, 
by biceps alone, two-thirds. Supination affected only by 
biceps. Pronation, one-third. Wrist extension and flexion 
about one-sixth of usual range. Passive extension to line 
of forearm, where the flexors, which are contracted, limit 
the motion. Thumb everted, and flattened like that of a 
monkey. Slight flexion and abduction. Muscles utterly 
wasted. The finger-joints are no longer swollen, but are 
excessively rigid, and have no movement. 278 
INJURIES OF NERVES. 
Electric test.—Below the shoulder no muscle has any 
electric contractility, and the sensibility to induced cur- 
rents is also diminished. Again the electricity brought 
on the burning, and was abandoned. 
Ordered daily etherization, and the fingers to be then 
freely moved. Shampooing to be continued, and the 
douche twice a da}7, with occasional blisters. 
January 29, 1864.—Electricity no longer renews the 
burning, and is to be daily employed. The gain was now 
rapid. Elexor power over the fingers came back, but no 
extension and no thumb motion. * 
February 23d.—Supination and pronation improving. 
Atrophy lessening. Ordered bandage roller to be placed 
in the palm, the fingers to be bound down over it, to over- 
come the extensors, which, within a month, have been 
contracting. 
On April 10, 1864, he was discharged, free of pains 
and having only three-fourths flexion of the fingers, with- 
out power to extend them. All the other motions were 
improving, and the thumb muscles began to respond to 
the will. Sensation perfect. 
The following case, which occurred recently in the 
practice of Dr. W. W. Keen, is a striking instance of the 
value of blisters in causalgia : 
Case 45.— Wound of musculo-spiral nerve. Dr. W. W., 
in 1855, received a ball through the arm, which injured 
the triceps and biceps and the musculo-spiral nerve. The 
wound healed readily. The patient thus describes his 
condition at the present time, March, 1871: “Numbness 
on back of arm,—more numb on back of hand, thumb, 
fore and little finger. The thumb and little finger can 
be but slightly extended, and the latter stands otf from 
the ring-finger and cannot be adducted. The arm mo- 
tions were feeble for several years, and are not yet fully 
restored. Nutrition much impaired, the shoulder flattened. TREATMENT. 
Its muscles, and those of the arm, somewhat wasted, and 
the areolar tissue between the triceps and biceps so far 
lost that the finger-tips can feel the hurt nerve enlarged 
and tender. No other part of the nerve is sensitive. 
There are tremors of the anconeus and supinator longus 
when in action. Injuries of the arm heal slowly. 
“ Burning pain began soon after the wound healed, and 
has lasted to date. It affects the back of the arm and 
hand; is worse in warm weather, in daytime, and when 
the part hangs down. A dull ache is felt in the nerve 
track, on the shoulder and over the scapular spine. At 
times the arm and hand swell, and are then more painful. 
The skin of the hand is dark, glossy, and tender. Douches, 
shampooing, and morphia, subcutaneously, have been of 
the most use. The constant use of water affords some 
relief. Found value in tonics, but has consulted many 
physicians in vain.” 
Dr. Keen advised blisters upon the burning surfaces. 
Dr. W. writes, “ I have tried the blisters, and desire to 
say that since they took effect the burning is entirely re- 
lieved. If I feel it again I shall, of course, return to 
them.” 
This interesting history of relief from causalgia after 
sixteen years of pain, also illustrates the tendency of 
neural trouble to pass towards the centres, and so to 
involve nerves unaffected by the primary injury. 
Constitutional treatment of traumatic neuralgia. — I have 
found no alterative remedies which seemed to me efficient 
in these cases. In old neuritis or sclerosis of nerves I 
have followed the popular therapeutics by giving iodide of 
potassium, and, in rare cases, corrosive chloride of mer- 
cury ; but I am not sure that they did any more effective 
service than by satisfying the patient to gain that time 
which is essential to the relief of almost all traumatic 
neuralgias. 280 
INJURIES OF NERVES. 
Large numbers of our army cases were intensely poi- 
soned by scurvy or malaria, or both, and in these persons 
the traumatic neuralgias seemed to me to be increased in 
severity by the general lowering of tone, and to react on 
the system with exaggerated power. In many cases it 
was only necessary to treat successfully the scurvy or ague 
in order to see very speedily diminish the pain which 
seemed to be due to the wound alone. 
The malarious element, even more than the scorbutic, 
appeared to foster neuralgia; but the presence of any 
cause tending to lower the standard of health was sure to 
make this affection doubly unmanageable. 
As regards the presence of ague in neuralgic cases of 
traumatic origin, it is to be remembered that the latter 
disease is sometimes most distinctly periodical, but is not 
made so by the most severe ague poisoning in a case with 
no original tendency to recur at a fixed hour. I saw at 
the Filbert Street Hospital a very instructive case of trau- 
matic neuralgia, in which the pain returned daily between 
4 and 5 p.m., the cause having been a gunshot injury of 
the crural nerve. After being some time in the wards, 
the patient was seized with a morning quotidian ague, 
which yielded easily to quinine, although the most liberal 
use of this drug and of arsenic failed to disturb the regu- 
lar recurrence of the evening neuralgia. 
The malarial element, when present, is only an ad- 
ditional cause of enfeeblenrent, and just to this extent 
serves to make more severe and lasting the recurrent 
neuralgia. In a word, there is apt to be, in any traumatic 
neural pain, a tendency to periodicity which seems to be 
a part of the natural history of such cases. 
Quinine in the largest doses exercised, as a rule, no cer- 
tain control over traumatic neuralgia ; and the same may 
be said of arsenic, which, in functional neuralgias, has so 
good a reputation. TREATMENT. 
281 
It is needless to dwell farther upon the indications in 
ague or scorbutic cases, but it should be clearly under- 
stood that, in every case, lowered tone is to be regarded 
as a serious obstacle to success in the treatment of these 
patients. We should always hear in mind that pain itself 
slowly but surely assaults the nutritive functions, and 
that it may be necessary to aid the system by iron, cod- 
liver oil, extracts of malt, and change of air. CHAPTER XII. 
TREAT MEN T—C ONTINUED. 
Neurotomy.—When every other means of relieving pain 
has been exhausted, the very grave question of the pro- 
priety of nerve section arises. As regards the simpler cases 
of lancet wounds and the like, requiring division of su- 
perficial filaments, nothing more need be added; but when 
the nerve to be divided is a great trunk, more serious 
considerations present themselves. In deciding for an 
operation, we are, of course, influenced by the extent and 
duration of the pain and by the fact that cases of common, 
aching, traumatic neuralgia depend very often on morbid 
nerve states, which, unless checked, gradually but surely 
extend up the nerve, and may thus get beyond the reach 
-of the knife, and so make permanent the tortures thej” 
occasion. On the other hand, causalgia, in my experi- 
ence, gets well in time; nor should we forget that in 
severing a great nerve we are probably condemning cer- 
tain parts to perpetual functional idleness; yet the earlier 
the operation the lower down it may be done, and the less 
will be, therefore, the loss of motion and sensation. 
When, after due regard to these points, an operation 
is decided upon, it becomes requisite to determine at 
what point it shall be done. To settle this, the limb 
concerned should be inspected with extreme accuracy, to 
learn what regions of skin or tissue seem to be painful, 
because it is essential to cut the nerve above all the pain- 
yielding branches. 
( 282 ) TREATMENT. 
283 
ISText the nerve should he examined with the utmost 
•care, in order to ascertain how far up it is hardened and 
enlarged. The examination in these cases is far more 
easy than might be supposed, because in many instances, 
owing to muscular wasting, the nerve trunks can be 
readily felt. By rolling or compressing the diseased 
nerve under the finger-tips, an attentive observer can very 
often learn whether or not it has undergone inflammatory 
or sclerotic change. 
It is, as a rule, desirable that the section should be 
made a short distance above the point at which the nerve 
ceases to feel enlarged and hard. If it be practicable 
to find even a little farther up the limb a spot where the 
nerve is neither swollen nor tender upon pressure, the 
operation should be done at that point. Usually, how- 
ever, nerves long diseased are sensitive up to and into 
their parent plexus, so that in practice the surgeon must 
content himself with a division some distance above 
the point where the nerve is obviously diseased. When 
it lies too deep for examination, it will be safest to 
operate high up in the limb, and, indeed, as a rule, the 
older the neuralgia, if of traumatic origin, the wiser it 
is to divide the offending nerve as near to the body as 
possible. 
The necessity for making section of the nerve at a 
point where its tissues are sound, arises out of the fact, so 
often insisted upon in these pages, that subacute neuritis 
and sclerosis inevitably travel inward along the nerve 
attacked, and that if above the line of division the sur- 
geon should leave any considerable amount of diseased 
tissue, his operation may be useless, and the morbid 
change continue to ascend the nerve, inflicting new tor- 
tures, and perhaps calling for further operative interfer- 
ence. The popular medical view attributes the return of 
pain after neurotomy to a reunion of the nerve ends; 284 
INJURIES OF NERVES. 
but unless there should be at the same time some return 
of the normal function of the divided trunk, it is more in 
accordance with the observed facts to believe that renewed 
pain, after section or exsection, is most often due to the 
presence or to the gradual increase in the central end of 
a nerve of the same disease which necessitated an opera- 
tion. In other words, the section should have been made 
higher up the nerve. 
Where the neuralgic cause is purely local, and the 
trunk unaltered by sequent changes, the operation ought 
of course to be done at the lowest point possible, and will 
then offer the best chance of success. 
The operative procedure must vary with the nerve, 
but there are certain indications to be fulfilled in every 
instance. If, when the nerve has been fully exposed, it 
should prove to be hard, red, and congested, the track 
should be followed upward, or a new incision made above, 
until a healthy point has been found. 
Simple division of the nerve is at present scarcely ever 
practiced. Hot less than two inches of its length ought 
to be removed, our object being to make reunion impos- 
sible, or at least very remote in point of time. It has been 
advised to cauterize the cut ends, but a more sensible plan 
is that of Malgaigne, who counsels us to double the nerve 
ends on themselves,—a measure which I should think 
very unwise as regards the central end, while I see no 
reason why the peripheral extremity should not be thus 
reverted, and, if necessary, secured by a removable loop 
of silver wire. 
With this precaution, reunion would be out of the ques- 
tion, but assurance may be made doubly sure by farther 
following the French surgeon’s advice, and interposing a 
piece of muscle or fascia. 
Such precautions are not vain, since even where two 
inches of nerve have been cut out, function has returned, TREATMENT. 
285 
and neuralgia also; and although, for reasons already 
stated, neither the return of sense nor of pain is in all 
cases conclusive as to the reunion of the nerve ends, it 
were wise to take every precaution against this occur- 
rence. 
It is desirable also to make, at the time of operation, a 
rapid microscopic examination of the portion of nerve 
removed, because only the microscope is fully com- 
petent to decide whether or not we have reached the 
region of normal nerve tissue, and until this is done we 
can possess no certainty that the operation will prove suc- 
cessful. 
On pages 288-291 will be found the statistics of these 
operations, but a careful study of the individual case and 
of the state of the nerve will offer far better ground for 
prognosis than any table of cases can ever furnish us. 
Should the pain recur, it has been advised to amputate 
the member, and this grave step has been frequently taken, 
although I do not conceive that it can ever be justified 
except where more than one nerve is involved, or where 
grave injury has rendered the limb altogether useless. 
% We are certainly able to make neural reunion impos- 
sible, and, if so, I cannot see what advantage amputation 
offers which resection higher up does not also afford. 
Moreover, when resection has failed, this more extreme 
step is not always successful, as the following curious case 
will show: 
Case 46.—A soldier had his leg crushed in a railway 
accident, August 1, 1862. Amputation was done August 
12th, at the junction of the lower and middle third. The 
stump was conical, the bone bare. In 1863, after a jour- 
ney, in which he was exposed to cold, he consulted Dr. 
Nott for intense neuralgia of the stump, which, in Sep- 
tember, 1863, Dr. Bayless amputated without relief. In 
.' May, 1864, Dr. Hott removed the stump again, taking off 286 
INJURIES OF NERVES. 
an inch of bone. Portions of two large nerves were found 
enlarged and engorged. The pain continued, and was 
intolerable. 
June 1st.—Dr. Nott opened the popliteal space and 
took out an inch of the trunk of the sciatic, and appar- 
ently about three inches of the popliteal and peroneal 
nerves, all of which were enlarged. jSTo relief followed, 
and in May, 1865, Dr. Nott, evidently thinking there 
might have been reunion, and, as he justly says, with 
“no very good physiological reason for so doing, dis- 
sected out the two large nerve trunks completely down to 
the extremity of the stump.” He does not say whether 
or not there had been reunion. Naturally, no relief 
ensued, and, in despair, the thigh was removed four inches 
above the knee, when the sciatic nerve was seen to he 
engorged and double its normal size. The neuralgia 
continued, and in August, 1865, Dr. Nott exsected the 
sciatic nerve at its point of pelvic exit, removing an inch 
and a quarter. The upper half only of this portion seemed 
healthy, hut whether it was studied with the microscope 
or not we are nowhere informed. Some relief was thus 
obtained, but the next day the pain returned, and then, 
as always, was referred to the end of the existing stump, 
and not to the lost limb,—a rare anomaly. 
Dr. Nott believes that his patient was really much eased 
by this final procedure, but that his craving for opium 
caused him to malinger. 
As an illustration of the tendency of neuritis to pass 
centrally, of its sclerotic results, and of the need for early 
resection higher up the nerve, this case is most instructive. 
I have stated in the accompanying table the more im- 
portant particulars of twenty-three cases of exsection of 
portions of nerves for traumatic neuralgia, with one of 
simple division. 
These include a variety of nerves, in five of which the TREATMENT. 
287 
exsected portion is described as variously altered, red- 
dened, indurated, or thickened, no statement being made 
as to the pathological condition of the remainder. 
In two only was there no immediate relief from the 
operation. In four the relief was partial, or came grad- 
ually, and in the rest it was entire and immediate. 
The future of these latter cases was less happy, since 
in five the pain returned at remote periods. As a final 
result, we learn that in sixteen the excisions effected 
lasting ease for the patient, although in several the an- 
nouncement as to the cure has been made too early to 
leave us sure of its permanency. 
In one case six excisions were practiced before relief 
came, and there was a relapse in eighteen months. 
Dr. Morton’s case was an interesting example of caus- 
algia. Five inches of the radial nerve were removed, 
without any good effect, and relief was gained by ampu- 
tation. In FTausick’s case, excision also failed, and am- 
putation succeeded. In the former example it is clear 
that the patient’s statements as to the seat of pain led to 
a diagnostic error with regard to the nerve involved. It 
is difficult to see why, in these cases, amputation should 
be allowed to replace neurotomy. 
If the statements as to loss of function and its re- 
turn are to be trusted, they show how rapid, in some cases, 
is the recovery of function, and how incomplete is its loss 
in others. The general conclusion is favorable to neural 
resection as a means of relief in extreme cases of trau- 
matic neuralgia. I am quite confident that if the opera- 
tion were not delayed so long the percentage of recoveries 
would be greater. I am equally certain, that were it 
always done in accordance with the very obvious rules 
which I have here laid down, it would be far more often 
successful. 288 
INJURIES OF NERVES. 
OPERATIONS FOR RELIEF OF 
AUTHOR. 
AFFECTED NERVE. 
OPERATION. 
CONDITION OF NERVE. 
Schuh, Op. Surg., 
p. 922. 
Inferior dental 
and mental. 
Excision. 
Not stated. 
Wardrop, M e d.- 
Chir. Tr., vol. 
xii. p. 206. 
Digital of thumb. 
Division. 
U 
Davies, Dublin 
Medical Jour., 
vol. xxx. p. 331. 
(From fracture.) 
Ant. tibial and 
musculo-cuta- 
neous. 
Excision of one 
inch of popli- 
teal. 
U 
Davies, Dublin 
Medical Jour., 
vol. xxx. p. 331. 
Posterior tibial. 
Excision of one 
inch. 
u 
U 
Ulnar. 
One-half inch 
excised. 
/ 
u 
Schuh, Op. Surg., 
788. 
Inf. orbital and 
inf. maxillary. 
Excision of parts 
of both nerves. 
U 
Sehuh, Op. Surg., 
Inf. max. and 
Excision of part 
Inflamed sheath 
791. 
inf. orbital. 
of inf. max. 
and altered 
nerve. 
Schuh, Op. Surg., 
791. 
Inf. max. and 
inf. orbital. 
Excision of part 
of inf. orbital. 
Normal. 
Schuh, Op. Surg., 
829. 
Radial. 
Excision. 
Not stated. 
B u z zell, J. M., 
Med. World, 
vol. i. p. 10. 
Int. plantar. 
Excision. 
Not stated. 
Teevan, Lancet, 
1832-33, vol. i. 
p. 654. 
Radial. 
One-half inch 
excised. 
Highly inflamed. 
Bickersteth, Rank- 
ing’s Abstract, 
vol. li. p. 221. 
Digital. 
Excision. 
Not stated. 
U 
Digital. 
One - half inch 
excised. 
11 
Wormald, Med. 
Times, 1863, vol. 
i. p. 343. 
Inferior dental. 
Three-quarter 
inch excised. 
“ * TREATMENT. 
289 
TRAUMATIC NEURALGIA. 
IMMEDIATE RESULT. 
REMOTE RESULT. 
REMARKS AND RESULTS AS TO FUNCTION. 
Entire relief. 
Return of pain at 
fourth month. 
Not stated. 
(< 
Pain returned at in- 
tervals, finally dis- 
appearing after 
twenty months. 
Numbness on end of thumb. 
ll 
Continued relief; no 
Paralysis of extension of foot. 
pain after three 
Partial sensory palsy, which 
months. 
was improving. 
ll 
Continued relief; 
well after two 
years. 
Not stated. 
U 
Continued relief; 
time not stated. 
Slight loss of tactile sense. 
Entire relief as to 
Continued relief for 
Not stated. 
inf. orbital. 
a time; return of 
pain in one year. 
Entire relief. 
Pain returned in 
Loss of sensation, which re- 
four months. 
turned in one month. 
Ll 
Pain returned in 
fifteen months. 
Not stated. 
Partial relief. 
Paralvsis in radial 
Six excisions of this nerve 
distribution. 
were practiced. The last 
caused entire relief, with 
return of pain in eighteen 
months. 
Entire relief. 
Continued relief. 
Not stated. 
Entire relief after 
Unknown. 
three weeks. 
Numbness in thumb, middle 
and index fingers. Sensa- 
Entire relief. 
Continued relief. 
tion finally restored. 
Loss of sensation in side of 
finger supplied by nerve; 
great gain in sensation in 
ll 
Continued relief dur- 
eight days. 
ing three weeks. 
Sensation incompletely lost. 
ll 
Continued relief dur- 
six weeks. 290 
INJURIES OF NERVES. 
OPERATIONS FOR RELIEF OF 
AUTHOR. 
AFFECTED NERVE. 
OPERATION. 
CONDITION OF NERVE. 
Morton, T. G. 
Unpublished. 
Radial. 
Five inches ex- 
cised. 
Not stated. 
Apew, D. H. 
Unpublished. 
Ulnar. 
Two and a half 
inches. 
Thickened and 
indurated. 
J. C. Warren, 
Boston Med J., 
vol. i. p. 101. 
Thumb nerves. 
Division. 
Not stated. 
<• 
Peroneal. 
Excision. 
U 
U 
Inf. plantar. 
Excision of one 
inch. 
U 
Carnochan, Am. 
Med. Monthly, 
vol. vi. p. 141. 
Sup. maxillary. 
One and a half 
inches excised. 
f 
Infla m e d and 
indurated. 
J. F. Miner, Buf- 
falo Med. Jour., 
vol. vii. p. 427. 
Median. 
Three inches ex- 
cised. 
Not stated. 
Gauelson, Med. 
and Surg. Rep., 
vol. xx. p. 293. 
Ant. tibial. 
One inch ex- 
cised. 
Not stated. 
Nausick, New 
Median and int. 
T h ree -quarter 
Neurilemma red- 
York Med. J., 
vol. ii. p. 174. 
cutaneous. 
inch excision of 
both. 
dened. 
W. Callender, St. 
Bartholomew’s 
Hosp. Repts., 
1870, p. 39. 
Comp’d fracture. 
Median. 
Exsection, one- 
quarter inch. 
U TREATMENT. 
291 
TRAUMATIC NEURALGIA 
IMMEDIATE RESULT. 
REMOTE RESULT. 
REMARKS AND RESULTS AS TO FUNCTION. 
No relief. 
No relief. 
Amputation a few days later 
with entire relief. 
The ulnar was found to have 
been injured by the ball. 
Entire relief. 
Entire relief. 
Loss of ulnar function, but 
nearly complete restoration 
in eighteen months. 
Gradual relief. 
No return in five 
years. 
Not stated: 
But little relief. 
Little relief. 
U 
Total relief. 
No return. 
a 
Entire relief 
? 
a 
Entire relief. 
No return. 
Paralysis of extensors and loss 
of sensation of hack of fore- 
arm. 
Entire relief. 
No return in three 
months. 
Paratysis of motion in foot; 
return of power in a few 
days. (Sic.) 
No relief. 
No relief. 
Sense of touch lost; hand felt 
dull and heavy. 
Amputation at line of upper 
and middle thirds. Entire 
relief. 
Entire relief. 
Continued relief. 
Not stated. 29 2 
INJURIES OF NERVES. 
I add, as examples, a history of amputation for causal- 
gia, by Dr. T. G. Morton, thecase of Corliss,* referred to 
on p, 202, a very interesting instance of exsection by Dr. 
D. Hayes Agnew, for which I have to thank Dr. W. W. 
Keen, who has more recently attended the man, and lastly, 
a remarkable case of bold and successful surgery by Dr. 
J. L. Stewart, of Erie. 
Case 47.—Injury of median and ulnar nerves by a bullet; 
loss of motion ; excessive causalgia ; exsection of four inches of 
median nerve ; no relief. Jos. II. Corliss, late private Com- 
pany B, 14th New York State Militia, aged twenty-seven, 
shingle-dresser, enlisted April, 1861, in good health. At 
1be second battle of Bull Run, August 29,1862, he was shot 
in the left arm, three inches directly above the internal con- 
dyle. The ball emerged one and a quarter inches higher, 
through the belly of the biceps, without touching the 
artery, but wdth injury to the median and ulnar nerves. He 
was ramming a cartridge when hit, and “ thought he wms 
struck on the crazy-bone by some of the boys for a joke.” 
The fingers of both hands flexed and grasped the ramrod 
$nd gun tightly. Bringing the right hand, still clutching 
the ramrod, to the left elbow, he felt the blood, and knew 
he was wounded. lie then shook the ramrod from his 
grasp with a strong effort, and unloosened with the freed 
hand the tight grip of the left hand on the gun. After 
walking some twenty paces he fell from loss of blood, but 
still conscious; attempted to walk several times, and as 
often failed. He wTas finally helped to the rear, taken 
prisoner, lay three days on the field without food, but with 
enough of water to drink, and had his wounds dressed for 
the first time on the fourth day, at Fairfax Court House. 
On the second day the pain began. It vms burning 
and darting. He states that at this time sensation wras 
lost or lessened in the limb, and that paralysis of motion 
* Mitchell, Morehouse, and Keen, op. cit. TREATMENT. 
came on in the hand and forearm. Admitted to the Doug- 
las Hospital, Washington, D. C., September 7,1862. The 
pain was so severe that a touch anywhere, or shaking the 
bed, or a heavy step, caused it to increase. The suffering 
was in the median and ulnar distribution, especially at the 
palmar face of the knuckles and the ball.of the thumb. 
Motion has varied little since the wound, and as to sensa- 
tion he is not clear. 
Peter Piueo, surgeon, IT. S. V., Medical Inspector 
U. S. A., opened the wound and exsected two or three 
inches of the median nerve. The man states, very posi- 
tively, that the pain in the median distribution did not 
cease, nor perceptibly lessen, but that he became more 
sensitive, so that even the rattling of a paper caused 
extreme suffering. lie “ thinks he was not himself” for 
a day or two after the operation. It seems quite certain 
that the pain afterwards gradually moderated, both in 
the ulnar and the median tracts. Meanwhile the hand 
lay over his chest, and the fingers, flexing, became stiffened 
in this position. 
About a week after he was shot, the right arm grew 
weak, and finally so feeble that he could not feed himself, 
lie can now (April, 1864) use it pretty well, but it is mani- 
festly less strong than the other. The left leg also was 
weakened, but when this loss of power first showed itself 
he cannot tell. He gives the usual account of the pain, 
and of the use of water on the hands and in his boots, as 
a means of easing it. 
Present condition, April 21, 1864.—Wound healed. 
Cicatrix of the operation two and a half inches long over 
median nerve. The forearm muscles do not seem to be 
greatly wasted. The interosseal muscles and hypotlienar 
group are much atrophied, and the hand is thin and bony. 
The thenar muscles are partially wasted. 
The skin of the palm is eczematous, thin, red, and 294 
INJURIES OF NERVES. 
shining. The second and third phalanges of the fingers 
are flexed and stiff; the first is extended. dSTails extraor- 
dinarily curved, laterally and longitudinally, except that 
of the thumb. 
Pain is stated to exist still in the median distribution, 
but much less than in the ulnar tract, where it is excess- 
ively great. 
lie keeps his hand wrapped in a rag, wetted with cold 
water, and covered with oiled silk, and even tucks the rag 
carefully under the flexed finger-tips. Moisture is more 
essential than cold. Friction outside of the clothes, at 
any point of the entire surface, “shoots” into the hand, 
increasing the burning in the median, sometimes, and 
more commonly, in the ulnar distribution. Deep pressure 
on the muscles has a like effect, and he will allow no one to 
touch his skin, save with a wetted hand, and even then is 
careful to exact tender manipulation. He keeps a bottle 
of water about him, and carries a wet sponge in the right 
hand. This hand he wets always before he handles any- 
thing; used dry, it hurts the other limb. At one time, 
when the suffering was severe, he poured water into his 
boots, he says, to lessen the pain which dry touch or fric- 
tion causes in the injured hand. So cautious was he 
about exposing the sore hand, that it was impossible thor- 
oughly to examine it; but it was clear to us that there 
was sensibility to touch in the ultimate median distribu- 
tion, although he describes sensation as somewhat less- 
ened in this region, and states that he has numbness on 
the inner side of the palm, and in the third and fourth 
fingers (ulnar tract). When the balls of the first and 
second fingers were touched, he said he felt it; but, on 
touching those of the third and fourth fingers, he refused 
to permit us to experiment further, and insisted on wrap- 
ping up and wetting the hand. lie thus describes the 
pain at its height: “It is as if a rough bar of iron were TREATMENT. 
295 
thrust to and fro through the knuckles, a red-hot iron 
placed at the junction of the palm and thenar eminence, 
with a heavyweight on it, and the skin was being rasped 
off my finger-ends.” 
Case 48.—Bullet wound of forearm ; causalgia ; relief by 
amputation. Corporal I. D., admitted for gunshot wound 
of arm, received some days before. A minie-ball entered 
near the middle third of forearm while it was in a flexed 
position, producing a considerable flesh wound, and splin- 
tering off a fragment of the border of the radius. Passing 
across the forearm, it also struck the arm some distance 
above the elbow, inflicting a slight wound. Both wounds 
were open, and there were two inconsiderable hemor- 
rhages from muscular branches in the upper wound. 
The patient suffered with most extensive causalgia, 
locating the pain principally along the radial site of the 
forearm and hand. The tissues of the entire arm and 
hand became shrunken and shriveled. 
Despite all local and constitutional treatment, including 
hypodermic injections of morphia sulpli., very little relief 
could be obtained. He was unwilling to submit to ampu- 
tation, which, it was feared, must eventually be done. 
Dr. Morton made an incision through the cicatrix in the 
region of the radial nerve, and removed four or five 
inches of the nerve. With the exception of slight con- 
traction of the diameter of the nerve, in the vicinity of 
the wound, no other abnormal change was perceptible. 
Very little relief followed the operation. A few days 
after, the patient being now very anxious for the opera- 
tion, the member was amputated; and, upon dissection, 
it was found that the ulnar nerve was injured in the track 
of the wound. Entire relief followed the operation, and 
is said to have been lasting. 
Case 49.—Repeated fractures of the humerus; one involv- 
ing the ulnar nerve ; anchylosis of the shoidder and elbow ; ex- INJURIES OF NERVES. 
section of the ulnar nerve to the extent of two and one-half 
inches; recovery of motion almost perfect, of sensation very 
great; entire relief from pain. Charles Kelly, aged forty, 
examined February 13, 1869. At ten years of age, he 
fractured his right liumerus, and since then it has been 
broken several times,—once with a firehorn, once with a 
brick, once purposely broken across his leg by a surgeon, 
once by a fall in a boat, etc. He is unable to specify the 
particular points of fracture or their number. After the 
first one, his elbow became anchylosed at a right angle, 
and subsequently to several of the fractures, he had fre- 
quent abscesses. In 1850, four inches of the humerus 
were resected after one of hi's fractures. 
In 1861, he broke his arm for the last time, but at what 
point he cannot say,—a simple fracture. He fell into a 
boat, five or six feet, and struck on his elbow, probably 
breaking off the internal condyle. He felt the shock 
in the “funny-bone” at the time. It was followed by 
repeated abscesses, extending not only around the elbow, 
but also about the shoulder-joint and arm, and resulting 
in the discharge of various pieces of bone. The pain in 
the ulnar nerve at the elbow' was only temporary, but 
repeated abscesses kept him at intervals for six years 
under the doctor’s care. 
In August, 1868, pain returned violently in the ulnar 
nerve at the seat of fracture, shooting into the hand, its 
exact locality not being now definable. It was a burning 
pain, and like “ running a jagged piece of wood into the 
hand.” The fingers twitched and shook violently. The 
pain was so severe that at each shoot “he jumped all 
over.” He could not sleep, and finally suffered so much 
that he demanded amputation of the arm of several sur- 
geons, but was refused. 
Dr. D. Hayes Agnew removed two and one-half inches 
of the ulnar nerve, just above the elbow-joint, in Sep- TREATMENT. 
tember, 1868. He lost but a few hours from his business 
after the operation, and no time during recovery. Since 
then he “ has never known a second’s pain.” For two 
months afterwards he had no sensation in the ulnar dis- 
tribution, as lie has repeatedly proved by sticking needles 
into it. To relieve it, he began to wear, a week after the 
operation, a rough glove filled with hair, the pricking of 
which during movements of the hand usefully irritated 
the integuments. In about two months sensation had 
begun to improve, and in three months his power to feel 
was as good as now. Motion began to return at the 
knuckles within a week, and gradually improved, till in 
three months it was perfectly restored. He took no medi- 
cine, and had not the use of the battery. 
Present condition, February 13, 1869.—Eight arm, ten 
and a half inches from acromion to head of radius; left 
arm, eleven and a half inches from acromion to head of 
radius; on right arm, ten cicatrices from abscesses, one of 
them four and a half inches long, on the outer border of 
the biceps, where the large piece of bone was removed; 
head of humerus nearly completely anchylosed to the 
glenoid cavity, but can be moved slightly in all direc- 
tions; elbow-joint anchylosed firmly at a right angle; ex- 
ternal and internal condyles both gone, and cicatrices over 
each. Over the internal condyle, and extending upward 
in the course of the ulnar nerve, is the incision made for 
its removal. The radius has three-quarters its natural 
rotation. The muscles are much wasted in the arm and 
forearm. What is left of the deltoid and biceps, say one- 
third, is active ; the biceps acting only as a supinator. The 
muscles in the forearm are wasted: right forearm, three 
inches below olecranon, nine inches; left forearm, three 
inches below olecranon, ten and a half inches. He has 
every movement of all the joints of the fingers, and every 
movement is perfect in extent, but he has lost about one- 298 
INJURIES OF NERVES. 
fifth or one-sixth in power. Sensation, save the softest 
touches, was well recognized as to locality. As estimated 
by the sesthesiometer, it is very defective, but cannot be 
measured accurately, owing to want of intelligence in the 
patient. 
Electro-muscular sensibility lessened, probably one- 
third. Electro-muscular irritability is not lost in any 
muscle of the whole extremity, nor diminished, save one- 
sixth in the last two ulnar interossei of the right hand and 
the hypothenar muscles. Ills hand is normal in appear- 
ance, except that from absence of use it is more delicate 
and smoother than is natural. The hypothenar muscles 
are one-fifth wasted, and the nails are quite clubbed. He 
has lost very much in general weight of body, and is not 
so robust as before his last fracture. Ilis memory, in 
some points, is not exact, nor is it so retentive as it used 
to be. 
The following case I quote without change from Dr. 
J. L. Stewart’s printed account: 
Case 50.—Bullet injury of the median nerve; causalgia ; 
excision of three inches of the median nerve; entire relief. 
“A. F. Swann, aged thirty-four, a native of Pennsylvania, 
a stout, robust man, and then captain of C Company, 16th 
Pennsylvania Cavalry, was wounded by a minie-ball at 
the battle of Cold Harbor, Virginia, May 28, 1864. The 
ball, fired at about ten rods distance, entered the left fore- 
arm two inches below the head of the radius, and passing 
obliquely across the elbow-joint, made its exit just above 
the inner condyle of the humerus. From the moment he 
was struck he suffered the most intense pain in the arm 
and hand, and lost a large quantity of blood. 
“The wound was dressed on the field, and healed 
kindly. The patient came home to Erie ‘on leave’ soon 
after, and remained until the end of June, when, there being 
no improvement in his case, he returned to Washington, TREATMENT. 
299 
and applied to Surgeon Bliss, U. S. V., then in charge of 
Armory Square Hospital, for relief. He was directed to 
use the electrical bath, which he did for four or five days 
without any apparent effect. The pain at this time was 
constant and excruciating, and confined chiefly to the 
palm of the hand; while the sensation was as if grasping 
a ball of red-hot iron. He demanded an operation, which 
was performed by Surgeon Bliss (about July 5,1864), who 
cut down through the wound of exit, and (so the patient 
was told) removed three inches of the median nerve. 
“ For two days after the operation the pain was very 
slightly less, but when the wound began to heal assumed 
its former intensity. 
“Mr. Swann had commenced the use of morphia 
hypodermically, about two weeks before this operation, 
and resumed it two days afterwards. From the first it 
required from three to five grains a day to relieve pain, 
and lie continued to increase the quantity gradually up to 
the time of the second operation, until he very generally 
injected ten grains a day, and has used as much as one 
drachm in three days. Both arms are covered with the 
punctures of the syringe, discolored, and the cellular tis- 
sue indurated. 
“ Mr. Swann consulted me in June, 1865, when I advised 
another operation; but he did not submit to it on account 
of being told by several physicians here and elsewhere, 
whom he consulted, that it would be unsuccessful. He 
again came under my care in June, 1870, six years after 
the receipt of the wound. His condition was most de- 
plorable, the pain in the hand, which was intensified by 
any excitement, was indescribable, and he was unable to 
attend to any active duties, except -while under the influ- 
ence of morphia. 
“lie suffered from irregular nervous chills of two or 
three hours’ duration, when he would be obliged, in the 300 
INJURIES OF NERVES. 
heat of midsummer, to lie by a hot stove with four or five 
blankets over him; the cold perspiration, meanwhile, 
streaming from him. His appetite was nearly gone; his 
bowels were habitually constipated; and the whole man 
was emaciated, feeble, and fretful. lie was willing to un- 
dergo any operation which promised relief, even amputa- 
tion of the arm. 
“June 27,1870.—Assisted by my friend, Surgeon Wool- 
verton, United States Havy, I proceeded to etherize the 
patient, which was accomplished with great trouble and 
difficulty. Fourteen ounces of ether were used, and an 
hour passed, the patient struggling violently and under 
great excitement, before the muscles relaxed and he be- 
came quiet. 
“An incision was made in the forearm, between the 
flexor carpi radialis and the palmaris longus muscles, 
three and one-half inches in length, terminating two 
inches above the wrist-joint; and three inches of the 
median nerve were removed. There was considerable 
venous hemorrhage after the operation, which ceased on 
the application of ice. The wound was closed by sutures 
and adhesive strips, and water-dressing applied. 
“As soon as patient passed from under the influence 
of the ether, he declared that ‘ the pain in the hand had 
left him.’ He slept three or four hours the first night 
under the influence of immense doses of bromide of po- 
tassium. He never used any opiate after the operation, 
and insists that he scarcely slept an hour for fourteen 
days, and had not a sound night’s sleep for twenty-six days 
after it; but his appetite returned at once, and he was in 
exuberant spirits at his freedom from pain. During the 
first four days after the operation chloral hydrate in 
drachm doses, and hyoscyamus, Cannabis Indica, etc., in 
heroic doses, failed to produce sleep, when I sent him to 
a quiet country home, and directed the free use of ale, TREATMENT. 
301 
with a generous diet. No medicine of any kind was 
afterwards necessary. 
“ There was no return of the chills after the operation, 
but he was much annoyed by a peculiar feeling of the 
surface, which he described as 4 craving of his skin for 
morphine,’ with burning of the feet; but these gradually 
passed away until he experienced no unpleasant or un- 
natural sensations. He has not suffered a moment’s pain 
in the hand or arm since the operation, now seven months 
past, and has gained forty pounds in weight, and is, in his 
own language, 4 in perfect health without pain or ache.’ 
He has good use of the small and ring fingers, and the 
paralyzed parts are well nourished. 
“ The operation was undertaken under the belief that 
there still remained near the original wound some injured 
portion of the nerve, and that relief might be given by 
severing its connection with the seat of pain, as the 
result has happily proved. 
44 What seem to me to be the important points in this 
case are—first, the u nceasing and great severity of the pain, 
from the moment of receiving the wound until I severed 
the nerve; second, the entire freedom from pain since 
the operation ; third, the vast amount of morphine used 
by the patient, estimated by him to amount to from two 
hundred and fifty to three hundred drachms, requiring 
the use of the syringe from six to twenty times every day 
for six years and some days; fourth, the rapidity with 
which he recovered from the effects of this long-continued 
and excessive use of morphine, suffering no inconvenience 
from its omission, in a few weeks after the operation ; 
fifth, the fact that the operation was undertaken in oppo- 
sition to the freely-expressed opinion of all the medical 
gentlemen here and elsewhere who had been consultedj 
after the failure of Hr. Bliss’s operation.” 
The following cases have been selected from my notes, 302 
INJURIES OF NERVES. 
or from our former essays, as illustrating the chief phe- 
nomena of nerve wounds and the modes of treatment. 
Some of the cases are incomplete, owing to causes which 
I could not control: 
Case 51.—Gunshot wound of axillary nerves; paralysis of 
motion; slight loss of sensation; burning on tenth day; great 
atrophy and contracted muscles; subluxation of fingers; nutri- 
tive changes; eczema in both palms; great improvement; dis- 
charged;* re-examined four years later. David Schiveley, 
aged seventeen, no trade, Pennsylvania, enlisted August,. 
1862, in Company E, 114th Pennsylvania Volunteers. 
Healthy before and after enlisting, except a slight attack 
of typhoid fever. 
At Gettysburg, July 2, 1863, while aiming, a ball en- 
tered one inch to the left of the middle line, and one inch 
above the sternal end of the clavicle. Exit on the pos- 
terior part of the right arm, at the middle line, two inches 
below the axilla. The ball passed in front of the trachea, 
broke the inner half of the right clavicle, went in front of 
the vessels of the neck and the subclavian artery, in front 
of the axillary artery, and below the humerus,—speaking 
of that bone as raised and abducted at the time. When 
hit, he thought his arm was shot off. It dropped, the gun 
fell, and, screaming that he was murdered, he staggered,, 
bleeding freely, and soon fell unconscious. When a little 
later he revived and raised his head, a second ball struck 
him in the right temporal fossa, and emerged through the 
right eye. He jumped up, ran a little way, and fell once 
more. When hit, lie lost all motion in the limb, which 
became numbed, but felt no pain. Two weeks lateiv 
feeble power to move returned gradually in the elbow,, 
shoulder, and arm, and after two months in the wrist and 
hand. 
* Gunshot Wounds and Injuries of Nerves. TREATMENT. 
303 
Treatment.—Cold-water dressings and means to relieve 
burning, but all ineffectual. The joints became swollen 
early, and the arm bent at a right angle. The hand, de- 
pendent, lay across his chest during a long period. He 
made some attempts at passive motion as he found the 
hand becoming stiff*, but no great good was thus gained; 
and, as the contractions took place and the joints grew 
worse, the wrist became moulded to the curve of the chest, 
on which it lay. 
About the tenth day, burning pain began in the palm 
and fingers, especially in the cushions of the fingers and 
the knuckles. It was at its worst a month later, and 
remained thus another month, after which it grew less. 
When at its height, he suffered from loud sounds, vibra- 
tions, and dry contact. The rubbing of his boots on the 
floor was the greatest annoyance, and this he relieved by 
wetting his stockings. Since October, four months after 
he was wounded, it has been unaltered. Sensation, little 
affected at the outset, has undergone no change of mo- 
ment. Voluntary motion, which grew better for awhile, 
suffered anew and increasingly as the nutritive changes 
developed themselves. When they first arose we have 
been unable to determine. 
Present state, December 17, 1863. Nutrition. — The 
wounded arm is shrunken, generally with well-marked 
atrophy of the supra- and infra-spinatus, deltoid, and 
biceps, the loss in the last two being fully one-half. Tri- 
ceps, no wasting of moment. Supinator longus and radial 
extensors, two-thirds loss. Flexors and extensors in fore- 
arm, one-half loss. Thumb muscles almost absent. Little 
finger and interosseal group, no loss. 
Contractions.—The flexor carpi ulnaris, palmaris longus, 
and flexor carpi radialis being strongly contracted, the 
wrist is bent at a right angle to the arm and drawn to the 
ulnar side; the extensor group is in like manner con- INJURIES OF NERVES. 
tracted, and the first phalanges, having thus been vio- 
lently extended while the wrist was flexed, have under- 
gone subluxation. 
The color of the back of the arm and hand is natural as 
far as the knuckles. Thence to the finger-tips the skin is 
tense, shining, hairless, mottled red and blue, abraded in 
spots; the nails curved, and the joints swollen and very 
tender. Palmar surface normal to wrist. The whole 
palmar face of the hand and fingers is polished, deep 
scarlet, abraded in points, and eczematous all over to a 
remarkable degree. The eruption followed the burning 
in about six weeks. The palm of the left hand is nearly 
equally eczematous. If his account may be trusted, it 
began to be so nearly a month before any eczema appeared 
in the wounded member. There is slight soreness on press- 
ure in the infra-spinatus, biceps, and flexors of the fingers. 
Voluntary motion.—Entire in the shoulder, though weak. 
The elbow possesses the middle third of its normal range 
of motion, but cannot be fully flexed or extended. The 
wrist, lying at a right angle to the arm, has only about 
forty-five degrees of extension. The thumb, nearly fixed 
in adduction, has slight and very feeble motion in all its 
joints. The Angers, bent back in extension, can be flexed 
to make a straight line with the dorsum of the hand. The 
flexors move the second and third phalanges through one- 
fourth of their usual range. They perform abduction 
and adduction well. 
Sensibility.—Tactility nearly normal. Localization of 
touch not quite perfect on the radial distribution in the 
hand. 
Pain.—The burning in the right hand is intense and 
constant. It is made worse by heat, exposure, drying of 
the skin, and dependent positions. He has kept it wet 
and wrapped up since October, 1863, which we believed 
might have made the skin troubles worse, until we saw TREATMENT. 
305 
this and other cases improve under treatment without any 
cessation in the application of the water. The left hand, 
which, it will be remembered, v7as also eczematous, is 
painful on pressure or touch, especially in the palm. He 
is positive that there is pain in that hand, and that it is a 
burning pain. Both hands are kept covered with loose 
cotton gloves, which he wets at brief intervals. He is 
especially fearful of having the right hand touched, and 
is nervous and hysterical to such a degree that his rela- 
tives suppose him to be partially insane. It is difficult 
even to examine him properly on account of his timidity, 
and his whole appearance exhibits the effects of pain, 
want of rest, and defective hsematosis. His treatment 
was constitutional and local. It answered admirably so 
far as gain in health and loss of pain were concerned. 
The after-means employed to cure the deformities and 
restore motion were partially successful. 
Remarks.—The electric tests satisfied us that in time 
the muscles could be restored, and assured us that the 
nerve communications were entire. The sensibility was 
slightly imperfect. Motion, though feeble from atrophy 
in some parts, was present in every group of muscles. 
It was limited by the contracted muscles and by the 
nutritive lesions in the joints. These two combined have 
damaged the power of movement, and left worse effects 
than usually result from partial paralysis affecting directly 
the motor nerves. Had proper passive motion been early 
used, there can be little doubt that the hand would now 
be far better than it is. 
January 25, 1867.—Health and strength very good; is 
attending the hospital school. Eyesight in right eye lost, 
of course; the lids are now constantly in contact, and do 
not look as unseemly as'before; they can be somewhat 
separated, showing the shrunken ball, the sclerotic only 
being visible. INJURIES OF NERVES. 
Motion.—Perfect as to range in shoulder and elbow; 
would be perfect in wrist, but is limited to three-eighths 
range by contraction of flexors. Power is somewhat 
diminished. Thumb perfect, but lies adducted. He 
can abduct it well. It is also everted so as to form the 
“monkey-hand.” The first phalanges are constantly at 
an angle of forty-five degrees in extension. They can he 
extended to ninety degrees voluntarily, and flexed to a line 
with dorsum of hand. The second phalanges have about 
the middle third of their range of motion, but not much 
force. The third phalanges cannot be moved voluntarily, 
hut can be moved passively well. The joints appear to 
be normal, save the subluxation of the knuckles. Ab- 
duction and adduction good. 
Sensation.—Imp roved. 
Contractions.—The flexors are contracted so as to limit 
extension of wrist; the extensors are not, I think, con- 
tracted, but by the constant flexion of the wrist at ninety 
degrees they extend the fingers as above. 
Pain.—In August, 1864, he began to lose the violent 
pain. It was not gradual, but one day he noticed sud- 
denly that his glove was dry, and yet he could use his 
hand well and without pain. It was not entirely gone, 
and he continued to wet his hand for some months; but 
it grew much better. Even now he feels dry rubbing in 
the palm of the hand and down to the finger-tips, and a 
loud noise, such as a wagon making a great noise in 
passing, or a sudden emotion, as seeing a person fall, etc., 
makes the same impression. In the left hand there is no 
pain. 
Appearance of hands.—Left hand perfectly normal. The 
eczema he is pretty sure passed away before he ceased 
wetting the hand. Right hand: color normal; no eczema. 
It continued longer than on the left hand, but also disap- 
peared before he ceased wetting it. It sweats a great deal; TREATMENT. 
307 
gets cold very easily; has no constant pain in it. The hair 
has been reproduced on the back of the hand, even to 
that of the fingers. Nails normal. Second and third 
phalanges a good deal wasted. Muscles of thumb a good 
deal wasted (say two-thirds), except flexor brevis, which 
is of nearly normal size. 
Nutrition.—Right biceps, eight and five-eighths inches; 
left, nine and one-eighth. Right forearm, three inches 
below olecranon, eight and five-eighths inches; left, nine 
and one-quarter. 
His nervousness is entirely gone, and he is perfectly 
well mentally. 
Electro-muscular sensibility is greater in right than in 
left arm throughout. Electro-muscular contractility very 
markedly diminished in right arm from shoulder down 
to hand. It is not more than one-half. He can use his 
hand so as to handle a fork. Could use a knife, but was 
always left-handed; holds a book well; cannot write; 
can touch every finger-tip with thumb. 
The temperature, taken April 20, 1867, was as follows:, 
fold between palm and thenar eminence the only place 
where the thermometer-bulb could be held and covered 
equally well by either hand. Right, paralyzed side, 97|°' 
Fahr.; left, sound side, 97|° Fahr. 
Case 52.— Gunshot wound of right lorist; sensation entire ; 
loss of flexor power and general motor loss from long rest on 
splint, adhesions, and want of proper treatment; great (jam.. 
T. M., aged seventeen, no trade, 121st Pennsylvania Vol- 
unteers. July 1, 1863, a ball entered the right wrist,, 
three and a half inches above the styloid process of the 
radius, and made exit one inch above styloid process of 
ulna, breaking both bones, but injuring no large vessel. 
The arm was on a splint for six weeks without change or 
passive motion, during which time many fragments of 
bone escaped. When admitted, the wrist was thickened 308 
INJURIES OF NERVES. 
by callus. The extensor tendons were tied fast by adhe- 
sions ; the hand a little swollen. The fingers were rigid, 
the thumb level with the palm and everted, its nail 
looking upward, — effects chiefly of the splint. The 
wound of entry was open. Sensation normal: the cal- 
lus had destroyed pronation and supination and wrist 
movements. The fingers were bound by the fixed ex- 
tensor tendons, so that they merely stirred in flexion. 
The thumb had all motions save only flexion, which was 
feeble. The interosseal motions were not lost, but limited 
by the flexing of the digits. Every motion or effort at 
motion caused tremor. 
The condition of the flexors seemed difficult to explain. 
They were extremely feeble, without their nerves having 
suffered by the wound. On faradisation, all the muscles 
responded, and, at the third sitting, they acted freely, so 
that the muscles could only have been suffering from long 
inertia and pressure. A rapid cure resulted. This case 
is a fair example of the mischief which too long use of 
the splint may occasion. It was sent to us as a case of 
neural injury. 
Case 53.—Gunshot wound of left 'popliteal space ; injury of 
sciatic nerve ; palsy of extensors ; loss of sensation ; causalgia ; 
gradual recovery ; nutritive phenomena ; probably cicatrix press- 
ure ; recovery. H. M., 26th Pennsylvania Volunteers, shot 
May 3, 1863, from without inward, through the left pop- 
liteal space, above the joint, between the tendon of the 
biceps and the head of the femur. At its exit the ball 
touched the posterior border of the inner hamstring 
tendon. 
The wound healed in four weeks. When hit he had 
great pain down the teg, and at once lost all power and 
all feeling, probably from local contusion or “shock.” 
.Since about June 7th, both feeling and motor power 
began to improve. On admission, June 18,1863, motion TREATMENT. 
was good throughout, that is, complete, but feeble. Sen- 
sation was nowhere absent, so that the gain must have 
been remarkable. 
Ever since the wound began to heal he has had great 
and increasing pain and numbness in the foot. These 
feelings seem to arise just above the wound, aind to run 
down to the toes. The pain is darting, pricking, and in 
the foot burning, with redness and oedema, which are 
made worse by heat, dependence of foot, etc. There are 
slight eczematous patches on the foot; the scar is hard, 
and when pressed upon causes pain down the leg. Bend- 
ing the leg at the knee and turning it inward, relieves 
the pain, which seems to have some relation to the cica- 
trix. There are no notable trophic changes, the calves 
differing by only the fourth of an inch. 
This condition was treated by frequent passive move- 
ments, by kneading the scar, by hot and cold douches,, 
and finally by faradisation, to improve the enfeebled 
muscles. Under these means the pain ceased, and he 
improved so as to be able to go on guard duty, October 
29, 1863. 
Case 54.— Wound of right sciatic nerve ; paralysis of exten- 
sors of foot; partial paralysis of flexors of foot and toes ; in- 
complete anaesthesia of foot; slight analgesia ; intense causalgia ; 
twitching of the toes. Peter C. K,, Pennsylvania, aged 
twenty-four, enlisted August, 1861, Company D, 48th 
Pennsylvania Volunteers; health good. August 29, 1862, 
he was shot through the right thigh a little above its 
middle. The ball went behind the femur, passing from 
without inward, and probably wounding the sciatic 
nerve. He felt a sudden intense pain and numbness of 
the foot, and leaped in the air. He hopped to a shelter, 
was taken to the rear, had his wounds dressed, and was 
then left on the field, where he says he lay seven daya 
without food, but with enough of water. He was then INJURIES OF NERVES. 
exchanged. The foot swelled within a week, and began 
to burn on top of the instep and toes. At first he had no 
power to extend the foot or toes, but could siiglitly flex 
them. The wound healed in a month, and at George- 
town Hospital he got on crutches,—the limb improving. 
In February, 1863, he could walk with a cane, and at 
this time the oedema disappeared. In the third week 
after the wounding, the toes began to twitch in a curious 
manner, moving laterally. This symptom still exists, 
although to a less degree. He thinks that touch and pain 
were totally lost in the foot at first, but admits that he 
might not have noted the sides of the foot near the mal- 
leoli as being normal,—if they were so then,—as they 
certainly were when he was admitted to our own wards, 
June 15, 1863. The foot is still somewhat swollen, and is 
worse in hot weather, when in bed, or when the limb hangs 
down ; cold, exercise, and water, whether cold or not, ease 
the intense burning pain. The foot and leg are scarred 
remarkably by repeated crops of papules, which break 
out every two weeks with unendurable itching, and then 
fade away, always leaving the foot much better for a time. 
When admitted, the muscular motions remained, as above 
described, and he could stand a moment on the leg, the 
calf of which measured two inches less than the other. 
The track of the internal saphena nerve is alone fully 
sensitive to touch,—elsewhere it is deficient. The flexors 
of the foot and toes respond well to the current of Du- 
chenne’s large coil,—the extensors have lost electro-mus- 
cular contractility and sensibility. 
Treatment June 15th.—Faradisation of extensors was 
practiced daily, and thorough rubbing of the weakened 
limb twice a day. The causalgia and congestion were 
treated by coating the foot with collodion, and hot and 
cold douches were used alternately to stimulate the en- 
feebled vessels. TREATMENT. 
311 
June ‘20th.—The extensors now respond to the cur- 
rents ; the burning is lessened. 
August 7th.—A period of great heat has increased the 
burning. Conium in olive oil was used by friction, but 
gave no relief; nor was any impermeable dressing of 
value, except a cover of oiled silk, with a well-applied 
bandage. 
October 29th.—lie has every motion of the limb; the 
burning is slight. He left the hospital on furlough, and 
returned November 20th, with the burning worse, and the 
sensibility still unaltered. Blisters by ammonia to the 
sole at length diminished the burning pain, and their 
repetition gave still greater relief. 
December 1st.—Transferred to the West, greatly im- 
proved ; said to have become much worse as to burning 
when the blistering was abandoned. 
Case 55.—Gunshot wound of arm; nerve lesions; loss of 
motion and slight loss of sensation ; relapse from neuritis, with 
contraction of flexors and “ claw-handrecovery. T. B. W., 
aged seventeen, Pennsylvania, bronzer, 29th Pennsylvania 
Volunteers. Sickly before enlistment, and has scars of 
scrofulous ulcers on the legs. Has had bronchitis severely, 
but washetter since enlisting. July 2d, at Gettysburg, while 
erect and aiming, was wounded by a ball, which entered 
the middle arm, behind the brachial artery, three-fourths 
of an inch below the uppermost part of the axillary hollow. 
The wound of exit was on a line drawn directly upward 
in the axis of the limb, half-way between the olecranon and 
internal condyle, six and a quarter inches above the latter. 
The scars are small. After falling he received a chest 
wound over the third rib above the left nipple, the ball 
emerging in the axilla one inch behind the tendon of the 
pectoralis major muscle, half an inch below apex of axilla. 
When first hit, he felt a knifelike pang in the wound, and, 
laying his gun down, he stuffed the freely-bleeding axilla 312 
INJURIES OF NERVES. 
with a handkerchief. The blood shot out in jets, and he 
soon fell senseless, remaining unconscious two hours. 
Within an hour the wound was dressed with water, the 
hemorrhage having ceased. No splint was used at any 
time. On examining the part after it was dressed, he 
found it absolutely motionless, even to the finger-ends. 
Next day he could move the digits a little, and more easily 
in a week. As to sensation, he is not certain. He thinks 
it was impaired for a long while on the outside of the arm 
and on the back of the forearm. July 8th, was sent to Balti- 
more, and thence to Philadelphia. He was then greatly ex- 
hausted, and on the afternoon of the 8th he began to have 
pain in the wound and down the forearm, with hyperses- 
thesia of the skin of the whole member, while at the 
same time the fingers and thumb became drawn in tight 
flexion, so that they could neither be moved nor ex- 
tended. Rest on a splint, cold dressings, and liberal 
diet rapidly improved him, and within a fortnight the 
arm became less sensitive and the nerves less tender. In 
a week the hand could be passively extended, while by 
slow degrees volition returned. After a time faradisation 
was employed, but as it renewed all the symptoms, the 
nerve tracks near the wound were leeched, ice-water freely 
employed on the whole arm, and active and passive move- 
ment added. December 20,1863, he was nearly well, and 
could act as orderly. 
The following case is valuable as showing the remote 
dangers of contusion in a person of bad constitution, and 
as a good illustration of the manner in which disease of 
one of the nerves of a limb may come finally to involve 
others. 
Case 56.— Contusion of right ulnar nerve at bend of elbow ; 
paralysis in ulnar distribution ; general extension of paralysis to 
the forearm and hand ; atrophy * Cliarles A. P., aged forty- 
* Gunshot Wounds and Injuries of Nerves, Case 16. TREATMENT. 
313 
four, enlisted December, 1861, Company G, 88th Pennsyl- 
vania Volunteers. A man of good education and of refined 
habits, but uncontrollably intemperate as to stimulants. 
He was, with this constant exception, in good health until 
injured at Cedar Mountain, July 12, 1862. He fell and 
struck the right ulnar nerve, at the bend of the elbow, on 
an angle of rock, causing the usual numbness and tingling 
in the ultimate distribution of the nerve. The sense of 
formication along the inside of the arm continued for 
some months, but the limb was in full use again the day 
after the accident. About December, 1862, the third and 
fourth fingers became weak, and gradually the loss of 
power affected all the fingers, the thumb, and the wrist. 
June 24,1868.—At this time, the date of his admission, 
he still possesses all the motions natural to the limb, but 
all below the elbow are singularly feeble, so that he is 
now unable to write. The motor paralysis is gaining 
ground. The loss of sensation is well marked in the ulnar 
distribution, and is gradually increasing in the median 
distribution. The localizing!; sense is also much confused. 
The point of injury shows no scar, but the ulnar nerve is 
tender to the gentlest pressure, and the median nerve is 
hardly less so. The hand is as warm as usual. There is 
no swelling nor burning, and the nutritive changes are 
not very notable as yet. The right forearm measures nine 
and a half inches; the left measures ten inches. 
The electro-muscular contractility is diminished in most 
of the muscles. The electro-muscular sensibility is slightly 
lessened. The treatment by faradisation and douches 
was used actively, but caused electric neuralgia, which is 
usually a favorable sign. 
July 10th.—Ho better. The neuralgia less, but the ex- 
tensors are contracting so as to limit flexion, and the 
tenderness of the nerves continues unabated. 
July lltli.—Ordered passive motion. Electricity to the 314 
INJURIES or NERVES. 
flexors and leeches to ulnar nerve track, with subsequently 
a long blister, one inch wide and eight long. The elec- 
tricity again increased the neuralgia, and accordingly it 
was laid aside, and the arm kept at rest, with repeated 
efforts to extend the fingers, and the use of a splint for 
this purpose at night. The leeching gave immediate ease 
as to pain, but as he drank incessantl}-, on every oppor- 
tunity, the chance of useful treatment was small. 
August 10th he deserted. 
November 19,1863.—He returned to the hospital drunk 
and materially worse. The right forearm now measured 
eightand three-eighths inches; the left nine and one-eighth. 
The flexors are greatly shrunken. The extensor group is 
atrophied and contracted, limiting what flexor motion is 
left. Everywhere below the elbow, and especially in the 
forearm, the power is lessened, but the electric properties 
are still quite good, and are nowhere lost. A sober man 
so situated would, without doubt, recover under the use 
of faradisations for a length of time. P.’s case is hope- 
less. Confinement injures his health, and every time he 
receives a pass it is used for the worst purposes. He was 
finally discharged on the 12th of December. 
Case 57.— Wound of left chest, causing paralysis of the 
great pectoral muscle, probably by injury to the external ante- 
rior thoracic nerve; extension of disease from the wounded 
nerve to the brachial plexus, with consequent loss of sensation 
and motion ; lesions of nutrition ; intense burning pains ; mus- 
culo-spiral and median principally affected. Stephen War- 
ner, aged thirty-three, farmer, New York, enlisted 
August, 1862, Company B, 18tli Pennsylvania Volun- 
teers. Healthy to date of wounding. At Locust Grove, 
November 27,1863, a ball entered the left chest below the 
first rib, half an inch beneath the clavicle, and two and 
a half inches from its sternal end. Passing, probably, 
under the arch of the subclavian artery it went backward TREATMENT. 
315 
and downward, and made exit two inches below the 
inferior angle of the left scapula, three and a quarter 
inches from the spine. The hall was fired by a skir- 
misher not twenty yards distant, and was received while 
the patient was in the act of bending forward to aim. 
lie fell, giddy, hut conscious; tried to move, but failed, 
and fainted from loss of blood. After several hours he 
revived, and discovered that the left arm and hand were 
sensitive throughout. On the radial side of the forearm 
there was slight numbness, a condition compatible with 
perfect tactile sensibility. Motion appears to have been 
lost or greatly lessened during some hours, and within a 
day to have become restored entirely. Ho doubt exists 
as to this point. 
Ho dressing was used until the third day, when cold 
water was applied. At this date the arm motions were 
complete below the shoulder, and there had been no pain. 
Soon after the cold dressing, to which he attributed the 
sequent symptoms, he was seized with neuralgic pain, 
which was principally in the median nerve distribution, 
but also on the outskle of the arm and shoulder, with a 
spot of intense pain at the deltoid insertion. The pain 
was darting and pricking in its nature. Coincidently 
with the pain, the joints of the fingers swelled and be- 
came sore, and this was especially the case with the 
thumb and the fore and second fingers. At the same 
time the shoulder muscles grew weak, flexion of the 
fingers feeble, and the flexion of the forearm became 
affected. All of these defects increased for several 
months, and the flexor group in the forearm wasted so 
much as to attract attention. The biceps, brachialis anti- 
cus and coraco-brachialis were in like manner atrophied. 
The pectoralis major was also thus altered at a still 
earlier period. The patient spat blood freely up to the 
eighth day, when the hemorrhage ceased, and he has had 
since then no pulmonary difficulties of any kind. 316 
INJURIES OF NERVES. 
February 19, 1864.—Admitted. 
Nutrition. — Atrophy of pectoralis major great, of 
shoulder muscles slight, wasting of biceps and other 
anterior and internal arm muscles considerable. Arm 
at the centre of biceps measures: left, ten inches; right, 
eleven and three-quarter inches. Forearm, left, ten 
inches; right, eleven inches. Left hand congested, 
dark, and cold. It grows cold easily. 
Sensation perfect.—The neuralgia has nearly disappeared, 
except in bad weather and about the insertion of the del- 
toid, where there is great tenderness and a good deal of 
hardening and deposit in the subcuticular tissues and 
about the bone. The only muscle which is hypersesthetic 
to any marked degree is the biceps. The course of the 
musculo-cutaneous and the median nerves is acutely 
tender upon pressure. 
Motion.—None in the pectoralis major, scarcely per- 
ceptible in the biceps, the supinator longus alone flexing 
the forearm. Extension of forearm perfect. The fingers 
act in flexion feebly, but are improving. The thumb mo- 
tions are also weak, but not lost. .Motion is now most 
limited by the state of the finger-joints, which, although 
no longer tender, are stiff and enlarged. So much im- 
provement has taken place very recently that we cannot 
be sure as to what motions were lost. Probably the prin- 
cipal nerves of the external cord of the plexus, namely, 
the musculo-cutaneous and the median, were those chiefly 
affected; certain filaments of the posterior strand, as the 
circumflex, also sharing in the diseased conditions. The 
remainder of the case would be irrelevant here. It was 
improving when admitted, and it gained ground with in- 
creased speed under a course of baths, gymnastics, and 
faradisation. 
We have here stated two striking instances out of 
several to show that a nerve being injured, it is possible for TREATMENT. 
317 
other trunks of the parent plexus to become secondarily 
affected. Two explanations are open to us: a reflex effect, 
orthe theorythat an inflammation originating atthe wound 
has traveled backward along the hurt nerve and fallen upon 
one or more stems of the main trunks. Let us examine 
this view in the light cast upon it by the cases before us. 
M. Duchenne (“De 1’Electrisation localisee,” second edi- 
tion, page 194) quotes a case almost precisely like number 
fifty-six, in which a blow on the ulnar nerve caused ulti- 
mate paralysis in other and remote nerves. Here is his 
explanation : “ These facts seem to me to demonstrate 
that there exists a sort of mutual dependence [solidarite] 
between all the nerves of a limb, so that no one can be 
suddenly destroyed [supprime] with impunity or without 
compromising the general innervation of the limb.” 
The fact was therefore a striking one to M. Duchenne. 
His explanation is assuredly not very happy, for although 
he has stated a theory which has a basis of truth, it is 
inapplicable here, since the simpler view which we have 
enunciated is amply defended by certain circumstances, 
which may or may not have been present in his case, 
but which were evident in our own. It wflll suffice to 
analyze Case 57; undoubtedly a wound of the external 
anterior thoracic, as was made certain by the position of 
the injury and the subsequent state of the pectoralis major, 
which this nerve supplies. On the third day, neuralgia, 
subacute inflammatory state of joints of fingers, and motor 
paralysis occurred. The phenomena affected chiefly the 
musculo-cutaneous and median nerves; in other words, 
the remaining nerve trunks of the external cord of the 
brachial plexus, from which the anterior external thoracic 
nerve arises. Add to this the long-continued and still 
existing tenderness in these nerve trunks in the limb 
itself, and we have evidence enough to make more prob- 
able that which at the start seemed a likely means of 
explaining all the facts. CHAPTER XIII. 
LESIONS OF SPECIAL NERVES. 
Wounds which involve the nerves of the neck, head, 
and face, though rare, are yet of more than ordinary in- 
terest to the physiologist, owing to their relations with 
the organs of special sense and expression. I have there- 
fore seen tit to report in this chapter the more remarkable 
histories of such cases which have fallen within my expe- 
rience. 
Injuries of the sympathetic nerve.—The only known case 
of direct mechanical violence to the sympathetic nerve 
was reported by the staff of the U. S. A. Hospital for 
Injuries of Nerves, etc.* My own attention was first 
drawn to the man by accidentally observing as he passed 
me in the wards that one pupil was contracted. He had 
been sent to us on account of an obscure affection of the 
brain, with headache, occasional faintness, and some loss 
of memory. His was the only well-marked case of direct 
wound of the sympathetic which I have seen. Its great 
physiological and clinical importance as positive proof 
that in man the nerve possesses the same function as 
it has been shown to exhibit in animals, authorizes me 
to quote it at length : 
Case 58.— Wound of right sympathetic nerve ; wound healed 
in six weeks; cerebral symptoms; contracted pupil; ptosis; 
lachrymation, etc. Edward Mooney,f aged twenty-four, 
* Gunshot Wounds and other Injuries of Nerves, p. 39. 
f Ibid. 
(318) LESIONS OF SPECIAL NERVES. 
319 
'enlisted July, 1861, Company C, 110th Pennsylvania 
Volunteers. He was perfectly healthy before and after 
enlisting, until wounded at Chancellorsville, May 8,1863. 
He was standing erect, and was looking toward the left 
side, when a hall entered his right neck, one and a half 
inches behind the ramus of the jaw at the anterior edge 
of the sterno-cleido-mastoid muscle. The hall passed 
across the neck, rising a little, and emerged immediately 
below, and a half inch in front of the angle of the jaw on 
the left side. He fell senseless, and, judging from the 
movements of his regiment, may have so remained during 
half an hour. On awaking he found his mouth full of 
clotted blood, wdfich he pulled out. The bleeding had 
■ceased. After a short rest he was able to walk nearly 
three miles to the rear, where his wounds were dressed 
with cold water. On his wray he discovered that his 
speech had become hoarse, difficult, and painful, and 
that deglutition gave rise to great uneasiness and to 
burning pains. He says the sensation of pain was felt as 
though behind the pomum Adami. After five days of 
great suffering and utter inability to swallow, he obtained 
some relief; but for a month or more was forced to take 
a little water after every mouthful of solid food. The 
power to swallow gradually improved, and is now as good 
as it ever was. 
A week after being wounded, he was able to articulate 
without pain, although hoarsely. This difficulty also less- 
ened by slow degrees. At present, July, 1863, his voice 
is still a little hoarse. During his recovery, which was 
rapid, the wounds healing within six weeks, he had a 
good deal of pain in the back of the neck. He says that 
he had headache, whenever after the injury he attempted 
to walk far, or exert himself; but he describes the head- 
ache as chiefly behind the right ear and in the back of 
the head, with some frontal pain. About one month after 320 
INJURIES OF NERVES. 
he was hurt, a comrade noticed the peculiar appearance 
of his right eye, and called his attention to it. A little 
later, it began to be troublesome in bright lights, and has 
remained so ever since, with of late some change for the 
better. 
July 15,1863—The pupil of the right eye is very small, 
that of the left unusually large. There is slight but 
very distinct ptosis of the right eye, and its outer angle 
appears as though it were dropped a little lower than the 
inner angle. The ball of the right eye looks smaller than 
that of the left. These appearances existed whether the' 
eye was open or closed, and gave to that organ the look 
of being tilted out of the usual position. The conjunctiva 
of the right eye is somewhat redder than that of the left, and 
the pupil of the right eye is a little deformed, oval rather 
than round. In a dark place, or in half-lights, the differ- 
ence in the pupils was best seen ; but in very bright light, 
as sunlight, the two pupils became of nearly equal size. 
The left eye waters a good deal, but has the better vision, 
the right eye having become myopic. In sunlight he sees 
well at first, but, after a time, observes red flashes of light 
in the right eye, and finally, after long exposure, sees the 
same appearances with the left eye also. He complains 
of frontal headache at present, and thinks that since the 
injury his memory has been failing, although recently it 
has improved. Idas lost flesh and strength since he was 
wounded. 
About the 30th August, the patient rode to the office 
of Hr. Byer, who examined his eyes with the ophthal- 
moscope, but found no abnormal retinal appearances. 
Mooney walked from Hr. Byer’s office to the hospital, an 
unusual exertion, as he was weak, and avoided exercise 
on account of the headache it caused. An orderly who 
was with him on this occasion, remarked to one of the 
hospital staff upon the singular appearance which his face LESIONS OF SPECIAL NERVES. 
321 
presented after walking in the heat. It became distinctly 
flushed on the right side, and pale on the left. This 
fact was afterwards observed anew by one of us. The 
patient had used exercise and had just come in. The right 
half of the face was very red. The flush extended to the 
middle line, but was less definite as to its limit on the 
chin and lips than above these points. He complained 
of pain over the right eye, and of red flashes in that organ. 
A careful thermometric examination, made during re- 
pose, showed no difference in the heat of the two sides 
within the mouth or ear. We regret that it did not occur 
to us to repeat this when the face was flushed by exertion. 
Under a tonic course of treatment he gained ground 
rapidly. The eyes became less sensitive, the pupils more 
nearly alike, the line of the lid straighter. He had several- 
attacks of faintness after exposure to the sun, and these, 
with occasional diarrhoea, retarded his recovery. lie was 
at last able to return to duty, and left for that purpose in 
October, 1863, nearly all of his peculiar symptoms having 
disappeared, and his general health having been altogether 
recovered. 
The case of Captain (now Commodore) Stembel, which 
Dr. William Ogle, in referring to one of my papers, seems 
to regard as a wound of the sympathetic, could not have 
been this.* The ball entered a little to the right of the 
median line, immediately above the hyoid bone, which 
it touched, and slightly broke, then passing across the 
neck directly beneath the left sterno-mastoid muscle, it 
emerged through the edge of the trapezius muscle three 
and a half inches from the middle line above and to the 
right of the superior angle of the scapula. He had com- 
plete but permanent reflex paralysis of the left arm, and 
* In an admirable paper on the Symptoms of Injury of the Cervical 
Sympathetic, Med.-Chir. Trans., vol. lii. p. 151. 322 
INJURIES OF NERVES. 
also more permanent palsy of the right arm. I cannot 
well conceive how the sympathetic of the right side could 
have been directly hurt by the missile, yet there was 
temporary loss of sight in the right eye, and even after 
two years slight ptosis, especially in the morning, con- 
tracted pupil, and imperfect vision, without unilateral 
flush, but with defect of secretion of sweat in the right 
neck, arm, and chest, and with rather excessive perspira- 
tion on the left side of the face and neck. 
That there was some affection of the sympathetic in 
this case seems most probable, but I incline to regard it, 
like the other paralytic symptoms of this extraordinary 
case, as due to a reflected irritation. 
Dr. William Ogle has reported an instance of probable 
destruction of the right cervical sympathetic by abscesses. 
In this case the eyeball was retracted, the palpebral fissure 
narrowed, the pupil contracted, the right side of the face 
redder and hotter than the left during repose, but after 
violent exercise or fever colder. The left side of the face 
alone sweated, and the right side of the mouth and tongue 
was complained of as being dry. 
The symptoms observed in this case differed very little 
from those of the history first quoted. In Dr. Ogle’s case 
there was wanting the droop in the outer angle of the 
■eye, which in Mooney was very apparent. The defect of 
secretion seems to be a late symptom, and in neither was 
there any notable nutritive alteration ; no lachrymal lesion 
or hypertrophy or change in the growth of the hair, such 
as I have occasionally seen in animals. In all other 
respects these cases reproduced the symptoms seen when 
we divide the cervical sympathetic in an animal. 
The subject needs further clinical illustration, and at 
present nothing can be said as to prognosis or treatment, 
while in most instances the diagnosis must be sufficiently 
clear. LESIONS OF SPECIAL NERVES. 
323 
The cerebral symptoms which may follow sympathetic 
nerve lesions demand particular attention in any future 
records of such wounds. In Mooney’s case they were 
loss of memory, vertigo, and headache, and were severe 
enough to keep him in a hospital long after the wound 
had healed. 
Injuries of the seventh or facial nerve—Mechanical injuries 
of this nerve are rare, and are valuable because they set 
in clearer light the precise meaning of symptoms which 
are common to all the modes of paralysis to which it is 
subject. 
Injury to the facial nerve causes simply palsy of the 
muscles of the face,'excepting such as are fed by the motor 
branch of the fifth nerve. It is therefore easy of recog- 
nition. The features relaxed and flabby and drawn to the 
uninjured side, the drooping mouth angle, the unwinking 
eye, constantly open, occlusion of light being effected only 
by rolling the ball upward, the unwrinkled forehead and 
the motionless nostril make up a pathological sketch easy 
enough of recognition whatever its cause. 
I have seen no case of traumatic injur}7 to the seventh 
nerve at its cerebral origin, where it is sometimes com- 
pressed by pathological formations. The records of 
injury to the nerve in its passage through the temporal 
bone are more frequent, but lesions of the nerve after 
exit on the face are rare, on account of its deep position 
and the protection afforded it by the neighboring parts, 
eo that it is not often hurt in this part of its course unless 
divided by the surgeon’s knife during removal of the 
parotid gland. 
Injuries of the facial, after emergence on the neck, oc- 
casion simple palsy of the face without any affection of 
the tongue or throat, and such lesions cause results pre- 
cisely similar to those which are produced by exposure 
to cold, the common cause of simple facial palsy. I saw 324 
INJURIES OF NERVES. 
in the Filbert Street Hospital a man who had been struck 
just below the meatus of the ear by a fragment of shell, 
which cut away the lower edge of the auricular cartilage 
and divided the facial nerve at the same time, so injuring 
the carotid that on the occurrence of hemorrhage it had to 
he tied. This man had all the usual signs of facial palsy; 
but taste, speech, and deglutition were unchanged. The 
palsied facial muscles finally underwent contraction, 
which, on the whole, rather improved the appearance o£ 
the face. 
The lesions of the seventh nerve (facial), which lie 
deeper in the ear, are diagnosticated by the addition to 
the palsy of certain symptoms, the occurrence of which 
depends upon the affection of the minor nerves related to 
the facial in its outward course. 
These nerves are in succession from within outward, 
the greater and lesser superficial petrosal nerves, which 
arise where the canal of Fallopius turns backward, and 
lastly, the chorda tympani given off in the descending 
portion of the canal. The first of these nerves after 
passing through Meckel’s ganglion is distributed to the 
levator palati and azygos uvulae, and probably also to the 
palato-glossus and palato-pharyngeus muscle. The second 
nerve passes from the facial to the otic ganglion, and 
through the latter is possibly related to the tensor tym- 
pani and tensor palati muscles. The third, or chorda 
tympani nerve, sends filaments to the submaxillary gland, 
to the papillae of the tongue, and to some of the fibres of 
the lingual muscles. 
When the lesion lies exterior to the chorda tympani 
nerve, we have simple muscular palsy of the face. If the 
cause lies beyond the tympanic nerve, we may have added 
dryness of the tongue and slightly impaired sense of 
taste, owing to the fact that the chorda tympani has under 
its control the erection of the gustatory papillae, the LESIONS OF SPECIAL NERVES. 
325 
secretion of the submaxillary gland, and the vessels of 
the tongue. Its paralysis by making dry the mouth aids 
in lessening the acuteness of gustation. 
When the injury involves also, as it commonly does, 
the origins of the two petrosal nerves, we have in addition 
partial paralysis of the palate and pharynx, with nasal voice 
and slight difficulty of speech and even of swallowing, all 
of which symptoms are more remarkably developed in 
.cases of diplegia of the face. To these may be also 
added in traumatic cases more or less injury of the sense 
of hearing. 
The palatal change consists in “a vertical relaxation 
or lowering of the palsied side of the velum, with dimin- 
ished height, and curvature of the posterior arch.” The 
soft palate is curved, its point turned to the paralyzed 
side, its base curved to the sound side,—the symmetry of 
the parts being totally lost. 
Since the occurrence of some of these symptoms as 
signs of pathological lesion of the facial in the canal of 
Fallopius has been disputed, I have been careful to 
look for them in undoubted traumatic injuries of this 
part, so that I believe my cases will be found on this ac- 
count to possess a more than common interest and value. 
The following history admirably illustrates in its pro- 
gress the simple palsy due to peripheral lesions, the addi- 
tion of the gustatory lingual and vocal symptoms as the 
deeper branches became involved, and finally, the fact so 
often alluded to in these pages, that inflammatory affec- 
tions of nerves sometimes extend in a central direction. 
Case 59.—Blow from a flail, breaking the left jaw and 
■paralyzing the left facial nerve; twitching of face muscles; 
gradually increasing disease of the deeper parts of the nerve, 
and affection of speech and deglutition. C. J., a florid, rather 
slightly-built man, who had in childhood scrofulous 
cervical glands, received a blow from a threshing-flail 326 
INJURIES OF NERVES. 
which fractured the angle of the left jaw and caused 
extensive inflammation of the face, followed by a large 
abscess. The jaw united, leaving him with slight neu- 
ralgia of the chin, owing no doubt to injury of the inferior 
maxillary branch of the fifth nerve. For a few weeks the 
facial muscles twitched a good deal, and as the inflamma- 
tion subsided, the suspicion which existed very soon after 
the blow, that the left face was palsied, became distinctly 
justified. After two months he came to the city to con- 
sult me. I found him suffering from an uncomplicated 
peripheral palsy of the left seventh nerve. All the usual 
muscles were palsied, the eye open, and the skin singu- 
larly relaxed. The tongue had all the normal motions, 
the voice being unaffected, and the taste perfect on both 
sides of the tongue. 
One year later I saw this case again. The palsy had 
diminished during two months, and then become worse 
without known cause; but his health seemed to have 
declined from this period, and he complained of some dif- 
ficulty in speaking for any length of time. The trouble lay 
chiefly in uttering the linguals. His tongue could be 
thrust out and moved laterally, but not bent upward 
with the usual readiness. The left side of the tongue was- 
tardy in recognizing all sapid substances, and he made 
frequent mistakes if urged to a hasty decision. The sense 
of touch in the tongue remained perfect, but the left half 
of the palate hung lower than the right, and was partially 
paralyzed, failing to respond to galvanism as perfectly as 
did the sound side. The palate was bent, the tip turned 
forward, and to the left, the upper portion curved towards 
the right, and the whole body of the palate twisted a little 
from left to right. These newly-acquired symptoms seem 
to me to have been caused by centrally progressive changes 
in the injured nerve. The patient died the year after of 
rapidly-developed tuberculosis. LESIONS OF SPECIAL NERVES. 
327 
The following case also amply illustrates the subject of 
wounds of the facial nerve : 
Case 60.—Gunshot wound involving portio dura; loss of 
electric contractility in the muscles of expression; no relief. 
William S. Sylvester,* farmer, aged twenty-two, born in 
Norway. In this country sixteen years. Eidisted for 
three years, September, 1861, Company!), 7th Wisconsin. 
In good health up to date of wound. At Gettysburg, 
July 1, 1863, he was shot, while standing, with a minie- 
ball, which entered the face an inch below the outer angle 
of the left eye. It passed backward and outward across 
the external auditory meatus, apparently injuring the left 
ramus of the jaw, high up, and finally emerged behind 
the lower half of the mastoid process, which it fractured. 
He fell instantly senseless, and reviving after a few min- 
utes, crawled away, and with aid reached the shelter of a 
house, where he was taken prisoner. After three days 
he was recaptured, and sent to the Satterlee Hospital, Phil- 
adelphia, and thence to us, August 2, 1863. The wound 
has never been painful, rarely more than sore ; fragments 
of the jaw escaped anteriorly, during the treatment, and 
also portions of the mastoid process at the wound of exit. 
The left side of his face swelled, and is still greatly en- 
larged. The conjunctiva of the left e}Te was a good deal 
inflamed at first, but is now free from inflammation, and the 
sight unaltered. Early in the case a good deal of blood 
escaped from his left ear, and the hearing was noticed to 
be, as it still is, rather dull. The inflammation about the 
articular portion of the lower jaw is such as to have 
caused great and painful difficulty in opening the mouth, 
which is so locked that it is impossible now to ascertain 
by touch, within the oral cavity, how7 much injury has 
been done to the bones. At present, August 4, the ante- 
* Gunshot Wounds, etc., op. cit. 328 
INJURIES OF NERVES. 
rior wound is healed, but the posterior is open, and an 
abscess, which formed below the left ear, is discharging 
very freely. The parts in front of the ear are confused 
in a mass of tirm plastic deposit. There is total palsy of 
the muscles of expression in the face. The brow and lid 
hang, the cheek is flabby, the mouth pulled toward the 
sound side. The tongue moves, but as the jaw is locked 
by the inflammatoiy deposit about the ramus, the cheek, 
and the articulation of the maxilla, it cannot be closely 
examined. He was long annoyed by the inability to 
cover his eye with the lid; but has now learned to roll 
the eye upward, so as to cover the iris. He then sup- 
poses that he has closed the lid. This same phenomenon 
was noted by Sir C. Bell in several of his earlier cases. 
The history of the present case is somewhat obscure, 
nor can we be absolutely sure as to whether the portio 
dura, which is paralyzed, was primarily injured by the 
ball, or secondarily affected by the large and firm deposit 
in front of the ear, which must of necessity have involved 
nearly all the facial branches of the nerve. The wound 
was dressed with water without other treatment. 
October 19, 1863.—The swelling has subsided one-half, 
but there is still dead bone in the wound, probably a 
piece of the ramus of the jaw. A mass of granulations 
fills the outer ear, but the hearing does not seem to be 
utterly lost. After tearing the granulations away, it was 
found that the membrane was gone, that there was some 
inflammation of the middle ear, and that below the bony 
meatus, and in front of it, dead bone could be felt. 
Faradisation of the face showed total loss of electric 
contractility in all the muscles supplied by the portio 
dura, and also in the posterior portion of the masseter, 
which had been injured by the ball and by the subsequent 
inflammation. 
As the face was still inflamed in September, no attempt LESIONS OF SPECIAL NERVES. 
329 
to treat the case was made till October. From October 
1st, however, to November 8d, be was faradised, although 
with slight hope of aiding him. At this date he was no 
better. On returning, December 3d, from a furlough, a 
cast of his face was made. The wounds were then healed, 
and the mouth could be opened. 
At this time we noticed that taste was duller on the 
left side of the tongue than on the right, and that the 
motions and tactile sense of the tongue were healthy. 
Electricity was used persistently up to January 10, 1864. 
It gave a good deal of pain, but in no way relieved the 
patient’s paralysis. In February he was transferred to the 
Veteran Reserve Corps. He had gained the power to 
chew his food, but suffered from all the annoyances of 
complete facial palsy. 
It will be observed that in this man’s case the injury 
was deep, the hearing wonderfully little affected, and the 
sense of taste distinctly altered. The mouth never became 
sufficiently open to enable us to study the palate. 
Case 61.—6runshot wound of left facial nerve; hearing lost; 
speech impaired; gustation affected; recovery. J. Gager,* 
aged forty-two, blacksmith, Company M, 14th New York 
Heavy Artillery, enlisted December, 1863. Health good. 
Wounded May 12th, at the battle of Spottsylvania Court 
House. The ball entered the left posterior neck one and 
three-quarter inches from the spine of the third cervical 
vertebra, and was cut out immediately behind and below 
the left ear, about two and a half inches beneath the 
meatus, and a quarter of an inch behind the jaw. The 
track of the bullet is unknown, except that it injured the 
ear, paralyzed the portio dura of the seventh nerve, and 
splintered the edge of the ramus of the jaw. The man’s 
head, at the time he was shot, was bent forward and 
* Gunshot Wounds, etc., op. cit. 330 
INJURIES OF NERVES. 
downward. He fell, conscious, bleeding freely from the 
ear only. After two minutes he arose and walked away, 
the blood still spouting from the ear until it was checked 
by a bandage over that organ. He did not sutler until 
the next day, when he had the usual inflammatory pains. 
The sight of the left eye is said to have become affected 
on the second day,—a defect which remains unchanged. 
The paralysis of the muscles was immediate, and his 
speech was at once rendered difficult, owing, as it seemed 
to him, to some loss of power in the tongue and lips.* 
Hearing was lost at once in the left ear. 
June 8, 1864.—The pains in the face, and the swelling, 
which was never great, are now less severe. The wounds 
are open, but healing. 
The nutrition is unaltered. The lines of the face are 
lost, the tip of the nose and the lower mobile portions 
of the face are drawn to the right. The left eyebrow 
has fallen a little. The tears run over the edge of the 
lid. 
The tongue is perfectly movable and under entire con- 
trol of the will. 
Speech perfect, except a slight impediment in articu- 
lating the gutturals, but there is more difficulty as to the 
labials. 
Special Senses.—The left eye sees only one-third as well 
as tlie right. 
Hearing is lost in the left ear. On washing out the pus, 
a mass of granulations was seen at the bottom of the ear. 
Possibly the bony meatus may have been fractured by the 
ball, but no bone escaped except pieces of the jaw, which 
came out with the ball. 
Taste.—There seems to be slight loss of gustation on the 
* It is to be remembered that the facial proper directly supplies several 
muscles more or less concerned in the motions of the tongue. LESIONS OF SPECIAL NERVES. 
331 
left side. Tactility is equally good on the two sides, both 
in the tongue and face. 
June 20th.—The sight is becoming worse. Dr. Dyer, 
who examined the patient with care, is of opinion that it 
was atfected before he received his wound. Induced 
electric currents give rise to slight movement in the left 
eyelid, and the elevator of the angle of the mouth. A 
rapid recovery was predicted, and, in fact, three days 
later voluntary power returned in the orbicular muscle 
of the eye. By July 27th, every motion had been re- 
acquired. 
In this case the ball must have injured the auditory as 
well as the facial nerve by shock rather than directly. 
Yet, as all the nerve tissues in the temporal bone alike 
suffered, the result was seen in loss of power and in dis- 
turbance of speech and taste. 
Case 62.—Gunshot wound of left portia dura nerve; total 
'paralysis of motion ; taste affected; tongue movements impaired; 
deafness on left side. John C. Dyre,* Pennsylvania, aged 
nineteen, machinist, enlisted May, 1861, Company E, 71st 
Pennsylvania Volunteers. Health good up to date of 
wound, at Gettysburg, July 3, 1863. While aiming, a 
ball entered just behind the left ear at the level of the 
meatus. It broke the mastoid process slightly, and was 
said to have gone forward and downward. It has not 
been found. He fell unconscious, and reviving within 
about two hours at a hospital where he had been carried, 
he found that he could not use the jaw, owing to pain in 
the ear. There was also pain in the left cheek and brow, 
left neck, shoulder, arm, and hand. The left arm was 
weak for several days. He thinks he may have fallen 
upon it. The pain was a neuralgic ache, not the pain of 
a bruise. Water-dressings were used after a vain search 
* Gunshot Wounds, etc., op. cit. 332 
INJURIES OF NERVES. 
for the ball. Within two days he had pain in the lower 
teeth and jaw on the left side. At the expiration of five 
weeks all pain disappeared, and the motions of the jaw 
returned. The ear was deaf from the first; hut he does 
not know whether blood flowed from it or not, or when 
pus first came from it. 
Present state, February 14,1864, eight months after recep- 
tion of wound.—The features are slightly drawn to the right 
in repose, and excessively so during laughter and speech. 
The left side is absolutely paralyzed. The inner canthus 
of the left eye is a little rounder than that of the right eye. 
The tears overrun the lid at times. Inability to close the lids 
on the left side; owing to which he has formed the habit 
of rolling the eyeball upward, so as to cover it with the 
passive lid. He then supposes that he has closed the eye. 
Chewing on the left side causes pain in the teeth, which 
continues for some time. Sensation is perfectly normal on 
the paralyzed side. Motion is of course utterly lost in all 
the muscles of expression. 
Electric test.—Hot the slightest contractility exists in 
any of the muscles of expression, on the left side, with a 
curious exception. The orbicularis oris in the upper and 
lower lips still responds to the current, but more remark- 
ably below than above. There is, however, no voluntary 
control over these parts. The buccinator alone of the 
masticating muscles seems to have its electric contrac- 
tility enfeebled, but.not wholly lost. 
Examination of special senses; tongue motions.—The up- 
ward and backward motion of the base of the tongue 
is awkwardly performed. In most of its movements 
the tongue inclines slightly to the right, but is capable 
of being drawn to the left side. The palate tip points 
towards the right side and acts imperfectly, so that food 
is apt to enter the nose. There is some further loss of power 
in the other muscles of deglutition, for he is often troubled LESIONS OF SPECIAL NERVES. 
333 
b;y food entering the glottis, while at times it is thrust hack 
again into the mouth. 
Speech.—He pronounces many letters with difficulty or 
imperfectly, so that his speech may be said to be a little 
thick, and he so describes it, referring the trouble to his 
lips and tongue. The labials are of course affected, but 
the guttural sounds are also imperfectly executed. 
Taste is apparently impaired over the entire left tongue. 
Electric state of tongue.—Ho loss of its electric properties 
was detected. Hearing on the left side was destroyed. 
The back part of the bony meatus was carious, and the 
membrane absent, perhaps from inflammation consequent 
upon the wound. 
Treatment.—The patient was industriously faradised for 
several months without the least gain in any respect. 
In this case, in which there was a deep injury of the 
facial nerve, taste, deglutition, and speech were all alike 
impaired. 
The following history is yet more conclusive: 
Case 63.—Ball wound of right neck destroying the ear and 
injuring the facial nerve; deafness; vertiginous attacks with 
forward impulses; facial palsy.; contracted muscles; nasal 
voice ; impaired deglutition; nutrition and functions of right side 
of tongue affected ; sense of taste diminished.—J., aged about 
thirty, was shot in 1864, the ball entering the right neck 
behind the mastoid process, through which it passed. Its 
course after entrance is unknown, except that it seemed 
to have traversed and destroyed the inner and middle ear. 
The tympanal membrane was gone, the bones of the 
middle ear absent, and a constant discharge occurred 
through the meatus and the wound of entry for many 
months, when finally the latter healed. 
The flowr from the ear, June, 1869, was slight, but the 
probe detected caries deep in the temporal bone. The 
missile was probably a small rifle-ball, not a minie. Up 334 
INJURIES OF NERVES. 
to the time of examination the man was deaf in the right 
ear, and was subject to attacks of vertigo, during which 
he would run forward a few steps and then rotate to the 
right several times, external objects seeming to move 
from left to right. 
The facial palsy was complete, and some of the mus- 
cles, as the levator anguli oris and zygomaticus, were con- 
tracted so as to give to his visage a most singular look. 
Xo electrical excitation was capable of inducing move- 
ment, but, as I have often observed in these cases, the skin 
of the right face was hypersesthetic. 
The voice was slightly nasal, and deglutition was awk- 
ward at times, while there was considerable difficulty in 
pronouncing certain sounds, especially the letters l and p. 
The right side of the tongue was of a light brown tint, 
and smooth ; the left rougher and covered with a moist 
white fur. The recognition of tastes was slow on the 
right side, and was plainly impaired, but not lost. The 
chief difficulty as to the lingual movements seemed to be 
in turning the tip of the tongue up and carrying it to the 
right side. The right palatal arches were lower than 
those of the left, and the palate, which was cedematous, 
was pulled to the left, the tip looking to the right and a 
little forward, but the whole organ being dragged to the 
left, a little past the middle line, by the action of the 
healthy opponent muscles. After a careful examination, 
I was satisfied that the right palatal muscles were less 
responsive to induced currents than the left. I should also 
add that the right half of the tongue was distinctly less 
in size than the left. 
I regret that this very instructive case passed out of 
my control and knowledge. It is an admirable confirma- 
tion of the opinions which Davaine, Saunders, and others 
founded upon pathological and physiological data. 
The treatment of these cases does not differ from that LESIONS OF SPECIAL NERVES. 
of other traumatic palsies; but in deep injuries of the 
ear by a missile, as in most nerve wounds involving 
closely related bone, the prognosis is usually hopeless, 
while in the external cases, even of severe wounds, 
recoveries are not uncommon. We should not, however, 
despair until long periods have passed and the muscles 
have been often and patiently tested by the galvanic cur- 
rent or by faradisation. 
I am indebted to Dr. Allison, resident physician at the 
Pennsylvania Hospital, for the following notes of a case 
of traumatic palsy of the left hypoglossal nerve, which oc- 
curred in the service of Dr. T. G. Morton. I have already 
referred to it in discussing the subject of trophic nerves. 
Case 64.—Pistol-ball wound of the left hypoglossal nerve. 
Alonzo B. Rogers, a colored lad, aged nineteen, was 
admitted into the Pennsylvania Hospital November 24, 
1871, suffering from a gunshot wound of the neck. The 
patient stated that the distance from which the pistol—a 
Smith & Wesson revolver—was fired could not have 
been more than five feet. 
The ball entered the left side of the neck one and a 
half inches behind and a little below the angle of the 
jaw. The wound of entrance was small and sharply de- 
fined. The examining probe passed upward and in- 
ward ; the ball could not be felt. No traces of the bullet 
were seen in the fauces. 
The tongue was found paralyzed on the left side as 
regards motion, but not sensation. When protruded, it 
turned toward the left or wounded side, and could not be 
held against the upper lip without the aid of the under. 
When the tip was pressed against the roof of the mouth, 
it turned toward the left side. The patient could readily 
press the tip against any point on the right side of 
the mouth, but on the left the attempt was attended 
with difficulty. There was no trouble in swallowing, but 336 
INJURIES OF NERVES. 
the patient thought he could not articulate as distinctly 
as formerly. 
Sensation was not at all impaired. Several tests were 
made at different times, but the result was always the 
same. Ho difference was discovered by means of the 
sesthesiometer. He could readily distinguish salt from 
sugar when placed upon either side. The right side of the 
tongue readily responded to the electric current, the 
wounded side did not, but seemed the more sensitive 
under the current. The wounded side of the tongue 
was notably atrophied before the patient was discharged. 
Several attempts were made to find the bullet, but all 
were unsuccessful. The wound healed without any diffi- 
culty, and the patient left December 12, 1871, the paraly- 
sis continuing unaltered. 
Lesions of the oculo motor nerves and of the fifth nerve.— 
Mechanical injuries of the motor nerves of the eye which 
do not at once involve loss of life are rare. I have several 
times seen cases of injury to the base of the brain affect- 
ing these trunks, especially the sixth nerve, there being 
at the same time no permanent cerebral or other symp- 
toms indicative of lesions of centres. There is at present 
such a case under treatment at the Hospital for Deformi- 
ties and for Hervous Diseases. 
The following case, which I report at length, stands 
alone in the history of oculo-motor-nerve lesions, and is 
interesting for its relation to the physiology of the iris. 
Case 65.— Pistol-ball wound involving the third, fourth, sixth, 
and ophthalmic branch of the fifth nerve ; secondary injury of 
the olfactory nerve ; death. 
December 31, 1870.—I saw in consultation with Dr. 
Morton the case of W. P., male, aged thirteen, who was 
accidentally shot on the 29th of December, in the after- 
noon. A pistol-ball entered the right temple, and, passing 
inward beneath the right optic nerve, lodged in the body LESIONS OF SPECIAL NERVES. 
337 
of the ethmoid hone. The nerve was pushed, upward, 
but suffered no other injury. In its path the ball cut 
the third, fourth, sixth, and ophthalmic branch of the 
fifth nerve where they pass across the wall of the cav- 
ernous sinus. About half an ounce of blood was effused, 
and found its way upward and forward so as to compress 
the olfactory bulb at its narrower central portion, which 
at the time of the post-mortem inspection was completely 
softened. 
When I saw the lad he was slightly drowsy, but could 
be very easily aroused, and answered all our questions 
with intelligence and promptness. 
The right eyeball was absolutely motionless, although 
the other moved readily. In the absence of better 
means, I placed an edge of paper across the eyelids in 
various directions so as to mark the edge of the cor- 
nea; but despite his utmost efforts, there was no measur- 
able movement in any direction. 
The iris was largely but not completely dilated. When 
I passed a light close to the eye, he was annoyed at the 
glare, but the pupil rested motiordess, as was equally the 
case when the eye was alternately covered and uncovered. 
When directed to regard a near object, the left pupil con- 
tracted, the right iris remained motionless. 
A little extract of Calabar bean was now placed on the 
eye, and in about fifteen or twenty minutes the iris had 
so contracted that the pupil wuis scarcely larger than a 
pin’s head. About an hour later atropia wTas put upon 
the eye, and within an hour the pupil dilated again, so that 
eight hours after it was larger than before. 
The eye was absolutely dry, there being no lachrymal 
secretion, and the ball was so completely insensible to 
touch that a finger rubbed on the cornea caused no annoy- 
ance. There were also anaesthesia and analgesia in the 
supra-orbital region and the lid. I endeavored to measure 338 
INJURIES OF NERVES. 
their extent; but the lad had become weary, and gave 
me unsatisfactory replies. I could only learn that there 
was sensory loss, but was unable to determine its exact 
area. 
The lid was moveless, except when feebly stirred by 
extreme effort of the supra-ciliary muscles, and the eye- 
ball projected from its socket. When the vapor of vine- 
gar wTas allowed to enter the left nostril, he knew it at 
once and named it, but the right had no perception of it 
either as an odor or an irritant, and such was also the 
case as regards mustard. I inferred from this that 
probably the nasal ophthalmic branch of the fifth had 
been injured; but the sectio cadaveris proved that both 
this nerve and the olfactory had been destroyed, so that 
neither irritations nor odors were readily felt. 
The patient became comatose by degrees, and died on 
the third day, when the conditions above described were 
found to exist. The symptoms presented by the eye cor- 
responded to the lesions demonstrated after death. The 
dull, insensible, and slightly-clouded cornea, the supra- 
orbital and nasal anaesthesia were due to the lesion of the 
fifth nerve; the motionless eye and fallen lid, with the 
non-secretion of tears and the projection of the eyeball, 
depended on the section of the oculo-motor and the fourth 
arid sixth nerves; and the absence of smell was owing to 
the injury to the fifth nerve and the subsequent pressure 
upon the olfactory bulb. 
The lenticular ganglion being undisturbed, our experi- 
ments on the effects of Calabar bean and atropia have but 
a limited physiological value, and only prove that ex- 
treme contraction and dilatation of the pupil are possible 
after total section of the fifth and third nerves, posterior 
to that body. 
Case 66.—Gunshot wound of the inferior dental branch of LESIONS OF SPECIAL NERVES, 
339 
the fifth pair. John Sehultze,* aged twenty-three, Ger- 
man, enlisted August, 1862, Company G, 26th Wisconsin 
Volunteers. His previous health was good. At Gettys- 
burg, July 3, 1863, while marching at a long distance 
from the enemy, a single shot, from some remote picket, 
took effect on his left cheek, over the lowrer edge of the 
malar prominence. It was probably fired from an eleva- 
tion, since it passed across the ramus of the jaw and 
entered the anterior margin of the trapezius muscle, 
whence, two weeks later, it was removed by Hr. Keen. 
The ball, a minie, was very much deformed. It some- 
what injured the ear in its passage, but although it 
crossed the ramus of the jaw obliquely, and probably 
broke off some splinters, it did not fracture the bone so 
as to affect mastication. The patient fell senseless when 
hit, and remained thus for at least half an hour. He had 
no pain. The whole left side of the face was devoid of 
feeling, and so continued until the second day, when sen- 
sation came back rather suddenly, except in a space, 
which included a large part of the ultimate distribution 
of the left mental nerve. 
The first and larger loss of sensory appreciation was 
probably a result of the local shock. When he recovered 
his senses, he found that the left arm was almost useless 
from loss of power. The fingers could be moved well 
enough, but the arm could not be flexed at the elbow. 
Sensation was but slightly altered. The arm was merely 
numbed. The right arm was also weakened, though to 
a less degree, but in it the sense of touch was defective 
to a remarkable extent, so that when he sought to undo 
his belt he could not feel the buckle. This was not 
merely a general shock or weakness, for his legs were as 
strong as usual, and he was able to walk to the rear un- 
* Gunshot Wounds, etc., op. cit. 340 
INJURIES OF NERVES. 
assisted. Motion and feeling returned within four days 
to the right arm, but the left recovered more gradually, 
and was still weak as late as August 10, 1863. 
During the first week there was great swelling of the 
neck, which was relieved when the ball was cut out. 
During September two or more small spiculae of bone 
escaped from the neck, below the chin. They were prob- 
ably fragments from the injured jaw. 
When Schultze entered our wards, August 10, 1863, 
his wounds were healed. The mouth could be but slightly 
opened, owing to the amount of deposit on the cheek and 
over the articulation. Early in his case, before swelling 
occurred, he could open and shut the mouth easily. Mo- 
tion gradually returned. 
August 12, 1863.—The skin of the left lower lip and 
chin is perfectly insensitive to pain and touch from the 
middle line to the left angle of the mouth, and, within a 
space between the middle line of the chin and a line drawn 
obliquely downward and outward, from the left angle of 
the mouth to the lower edge of the inferior maxillary 
bone. The curve of the lip within the mouth is dead to 
touch, and so also are the gums in this region. The teeth 
and gums of the left lower jaw are generally less sensi- 
tive to touch and pain than is natural, but they are not 
altogether deprived of sensation. The external region, 
defined above, has no appreciation of touch or pain, but 
the point of exit of the nerve is the seat of neuralgic 
pain, and pressure on this point is felt by the patient, so 
that even here the deeper tissues are less affected than 
the skin. The most intense applications of the electric 
brush to the dried and powdered chin caused no pain. 
Wet conductors, which threw the subjacent muscles into 
contraction, seemed to cause deep-seated pain. Under 
the use of dry conductors, Schultze improved, but not LESIONS OF SPECIAL NERVES. 
341 
until the thirtieth application of the battery, which was 
used daily. 
November 19th.—He returned to duty as orderly. 
November 27th.—The anaesthetic region has gradually 
narrowed, and is now within a triangle, the base of which 
is the border of the lip, and the apex of which lies at the 
edge of the chin, immediately below the left angle of the 
mouth. Electricity was steadily used during four months, 
when, the anaesthetic space being one-third of its original 
size, the teeth and gums more sensitive, and the jaw mo- 
tions good, treatment was abandoned. "Within twenty 
days the anaesthetic space again enlarged. It was more 
speedily lessened in size by twenty electrizations. As he 
could now chew well and was in other respects healthy, 
and desirous of being in the field, he was sent to duty at 
the close of February, 1864. Whether or not the area of 
insensibility increased afterward, we cannot state, since 
the patient finally passed from under our observation. CHAPTER XIY. 
NEURAL MALADIES OF STUMPS. 
The nervous affections of stumps are chorea, neuralgia, 
neuritis, and sclerosis. They have received but little 
notice at the hands of neuro-pathologists, and, indeed, 
the physiology of stumps, a comprehension of which is 
necessary before studying their diseases, may be said to 
have been almost entirely neglected. 
I have therefore thought it fitting to introduce here an 
original study of the vital conditions of stumps before 
speaking of their diseases. 
Functional and other changes after amputation.—The ampu- 
tation of limbs gives rise to certain functional and other 
conditions which have never as yet been fully studied. 
According to my own experience, removal of large limbs 
tends to cause plethora, more rapid pulse, and in very 
many cases greater tendency to sweat. The tissue 
changes in the stumps which follow amputation have been 
pretty fully described by surgeons, and need not be con- 
sidered here, save as to certain practical points. In many 
cases the stumps, after wasting for a time, seem to gain 
in bulk, although this is not always the case, for it occa- 
sionally happens that both muscles and bone undergo 
remarkable and permanent atrophy. Perhaps in chosing 
a line of amputation, more attention should be paid to 
the points at which the nerves enter the muscles or the 
bones, since, if these can be respected, wasting will be less 
( 342) NEUKAL MALADIES OF STUMPS. 
343 
likely to occur, and the mobility and nutrition of the 
stumps will benefit by the precaution. 
Neuromata of stumps.—At the ends of the severed 
nerves, tumors of various size form. They are chiefly 
masses of connective tissue, over which the nerve fila- 
ments spread, and are finally lost to view. In most thin 
stumps these enlargements can he easily felt, and very 
often a thickened nerve trunk running from them is also 
readily perceptible. Perhaps no stump is altogether with- 
out these tumors, which are far too apt to be regarded by 
surgeons as the cause of neuralgia, a disease usually due 
in stumps to neuritis or the sclerotic state which it is apt 
to occasion. In all the stumps I have studied, these neu- 
romata existed, and are, I think, to be looked upon as 
inevitable appendages. 
In very many stumps, the neuromatous tumors in which 
the nerves end are united to one another, or are adherent 
to the bone and the cicatricial tissue of the muscles and 
skin. Owing to this fact, and to sclerotic conditions of 
the nerves which lessen their natural elasticity, they fail 
to yield readily when stretched, and for this reason are 
apt to suffer when the limb is suddenly and violently 
moved, as in spasm or by the will. Only in this manner 
can I explain the occurrence of pain and inflammation 
due to such motion. A man previously well has an 
unusually violent and abrupt spasm of the deltoid, such 
as has often before occurred to him in a lighter form, 
and always with painful results; but on this occasion the 
pain is excessive and continuous; the nerves then become 
tender, neuralgia follows, and we have at last a well- 
marked case of neuritis. Although these are rare cases, 
they are not to be overlooked in seeking for causes of 
inflammation, and seem tome to be explained by the facts 
I have mentioned. 
Neuro-physiology of stumps.—When a limb has been 344 
INJURIES OF NERVES. 
removed, the stump which forms is liable to certain nerv- 
ous disorders, which are often intractable. The part 
which they affect exists under physiological conditions 
so newT and peculiar that it is desirable to comprehend 
them as fully as possible before proceeding to study these 
maladies. So far as I am aware, there is but one essay 
on the physiology of stumps, and this by no means 
covers all the ground. My own information on the sub- 
ject is derived from the careful study of ninety stumps, 
and from the statements of fourteen persons who have 
consulted me on account of neuralgia or choreiform move- 
ments of their stumps, as well as from dissections of such 
parts. 
Sensibility.—The sense of touch, which soon after ampu- 
tation is oftentimes dull or deficient in limited areas of 
stumps, becomes in time more acute, but is rarely per- 
fect. In cases of arm amputations remote from the date 
of operations, I have often found portions of the skin of 
the stump almost devoid of tactile feeling, while the rest 
of the stump showed as distinct an appreciation of the 
distance of two compass points as regions similarly 
placed in the corresponding limb. 
Sense of pain.—A large proportion of stumps, especially 
those of the arm, are hypersesthetic, or have some un- 
pleasing sensation as a consequence of any, and especially 
of rough contacts. Lateral pressure is very annoying 
to many, and if long continued is apt to cause aching 
neuralgia; complete anaesthesia is much more rare. I 
have seen one case in which the entire end of the limb 
was insensible to a needle, but this was the remote, and, 
I may say, the fortunate consequence of a severe attack 
of painful neuritis. 
The sensitiveness of stumps varies greatly with the 
season of the year, with the weather, and with consti- 
tutional conditions, while of course there are many in- NEURAL MALADIES OF STUMPS. 
345 
stances of well-cushioned stumps which are no more sen- 
sitive than other parts. As a rule, great heat or imperfect 
ventilation of the stump where artificial limbs are worn 
occasions increased sensibility, with excessive cutaneous 
congestion ; so that in our July weather many persons are 
unable to endure their false limbs. 
Cold has usually the effect of causing pain in the part 
with referred sensations, and both cold and heat are apt, 
in rare cases, to occasion twitching or even choreic move- 
ments of the stump. So well are these facts known to 
many patients that they pay extreme attention to the 
temperature of the part, and prefer to guard it in winter 
by some unusual amount of covering, knowing perfectly 
well that it is singularly sensitive to thermal changes. I 
have found this to be more remarkably true of the arm 
than the leg, and especially so of thin stumps, perhaps 
because of the insufficient protection they afford to the 
nerves and of the defective circulation produced by want 
of exercise. 
But besides the influence of palpable changes in tem- 
perature, stumps are subject to a variety of unpleasant 
or painful sensations whenever a change of "weather is 
about to occur, from dry to wet, or rather when we are 
about to have an easterly storm. The certainty with 
which some persons who have had limbs amputated can 
predict such a change is curious and puzzling, and 
renders likely the existence of peculiarities in these 
storms which our instruments have as yet failed to dis- 
cover. 
After questioning closely fifty persons, the following 
are the conclusions reached : 
Less than half the number feel no nerve sensation upon 
the coming or during the continuance of an east wind; 
of the remainder, two-thirds insist upon their power to 
foretell such a change of weather, and are positive that 346 
INJURIES OF NERVES. 
they are unaffected by the onset of a thunderstorm, or 
of southerly rains, although as to the latter point some 
of them feel doubtful. 
I have never had the chance of absolutely testing the 
power of any such patients to predict a storm, but the 
intelligence and character of a few of my witnesses lend 
force to statements like their own coming from less 
responsible persons. 
Aching pains and twitching of the stump muscles, with 
sensations of various kinds, motor or sensory, referred to 
the lost part, are the symptoms which are described as 
preceding an east wind,* and in many cases as persisting 
until their sudden cessation foretells an impending change 
of weather. 
Many stumps are liable to slight pain during the per- 
formance of certain normal reflex actions. I have seen 
one person who has a sharp pang in the arm-stump 
(left) when he yawns, and others who always suffer more 
or less in leg-stumps (thigh) during defecation. The 
most common of such referred sensations is the pain 
which is felt in thigh-stumps during micturition. A 
highly intelligent gentleman first mentioned this to me, 
and assured me that it was quite frequent among the am- 
putated, with numbers of whom his business had brought 
him into relation. Since then I have had repeated evi- 
dence of the truth of his statement. The pain comes on 
at the beginning of the act of passing water, and is felt in 
the stump, and sometimes down the lost leg. Pro- 
fessor Gross, in his Surgery, speaks of incontinence of 
urine as apt to follow for a time thigh amputations. I 
have only seen two persons in whom there was any such 
symptom at a later date. Both were high amputations. 
* As every physician knows, these feelings are common to many suf- 
ferers from rheumatic disease or maladies of the bones. NEURAL MALADIES OP STUMPS. 
347 
Gueniot* speaks of the same symptom in a woman who 
lost her arm at the shoulder. 
Motor phenomena.—The ease and dexterity with which 
many persons use their stumps evince how little the 
muscles may suffer. Excepting near to their attachment 
to the divided bone or to the tissues of the cicatrix, the 
muscles I have examined were sound. In most mobile 
stumps they react with electricity as well as those of the 
entire limb, and in patients afflicted with twitching or 
choreoid movements, so called, they are often over-excita- 
ble, and very sensitive to the pain caused by induced 
currents. 
The motility of muscular stumps is very apt to be dis- 
turbed by mental emotions, and even the most healthy 
are liable, when excited, to sudden and annoying dis- 
charges of motor nerve power. These are sometimes 
only fibrillar spasms, in others they are cramp-like, and 
in some are productive of sudden and violent motion in 
one direction. They are apt to cause pain, even severe 
pain, and are most common in the arm and in patients 
who suffer constantly with twitching of the stump. I have 
attended one gentleman who has a very useful arm-stump, 
but who at times is compelled to seize and confine it at the 
side in order to terminate a spasm of the deltoid, which 
gives great pain in the nerve tracks, and which has once at 
least been the starting-point of a sharp attack of neuritis. 
While emotion may cause involuntary movement, it may 
also check choreiform spasms, as in the case of Colonel 
Parr, whose arm-stump was never at repose a moment, 
except when, at Cedar Mountain, his regiment being cut 
off for a time, and in danger of being taken,—the restless 
limb was seen for some hours to hang motionless at his 
* D’une Hallucination du Toucher, Journal de la Physiologie, 1861, 
p. 418. 348 
INJURIES OF NERVES. 
side. In another instance of remarkable and constant 
motions of an arm-stump, they ceased for some hours 
after the patient had emerged unhurt from the wreck of 
a railway accident. 
Sensory hallucinations.—Ho history of the physiology of 
stumps would be complete without some account of the 
sensorial delusions to which persons are subject in con- 
nection with their lost limbs. These hallucinations are 
so vivid, so strange, and so little dwelt upon by authors, 
as to be well worthy of study, while some of them seem 
to me especially valuable, owing to the light which 
they cast upon the subject of the long-disputed muscular 
sense. 
Nearly every man who loses a limb carries about with 
him a constant or inconstant phantom of the missing 
member, a sensory ghost of that much of himself, and 
sometimes a most inconvenient presence, faintly felt at 
times, but ready to be called up to his perception by a 
blow, a touch, or a change of wind. 
Ambrose Pare* remarked upon the curious fact that 
the absent limb is felt as if existing, and in some of the 
earlier treatises on amputation the same symptom is ex- 
pressly noticed. Among ninety cases, including a great 
variety of amputations, I have found but four cases—two 
of an arm, the others of legs—in which there never had 
been delusion as to the presence of the absent member. 
None of these cases were in any way singular as to 
the state of the stump or other symptoms, but three of the 
four were persons of inferior intellect, laborers by occu- 
pation. In one of the arm cases, I carefully faradised the 
brachial plexus without obtaining from the patient any 
indication of subjective feelings referred to the lost parts. 
Nor was he ever conscious, under any circumstances, of 
* (Euvres Completes, edit. Malgaigne, t. ii. pp. 221 and 231, Paris. NEURAL MALADIES OE STUMPS. 
349 
such phenomena. . I confess myself unable to explain 
these exceptions. 
The sensation of the presence of the part removed ex- 
ists in many persons as soon as they come from under the 
influence of the anaesthetic used at the time of the ampu- 
tation, but in others it only arises after they cease to sutler 
pain, being rarely delayed beyond three weeks. The more 
healthy the stump, the less perfect after a time becomes 
the sense of the existence of the limb removed, while it 
is liable to be recalled by a blow or anything which 
causes a return of subjective sensations. In one case 
the foot was scarcely felt as present, when a second 
amputation above the knee restored permanently the 
faded consciousness of the part below the first point of 
operation. Even in those who are least conscious of the 
missing part, I have amazed them by suddenly recalling 
it with the aid of a faradaic current applied to the nerves 
of the stump. It is not easy to forget the astonishment 
with which some of these persons reawaken to a percep- 
tion of the long-lost leg or arm. 
I recently faradised a case of disarticulated shoulder 
without warning my patient of the possible result. For 
two years he had altogether ceased to feel the limb. 
As the current affected the brachial plexus of nerves, 
he suddenly cried aloud, “Oh, the hand, the hand!” 
and attempted to seize the missing member. The phan- 
tom I had conjured up swiftly disappeared, but no spirit 
could have more amazed the man, so real did it seem. 
Very many have a constant sense of the existence of the 
limb, a consciousness even more intense than exists for the 
remaining member. “ If,” says one, “ I should say I am 
more sure of the leg which aint than the one which are, 
I guess I should be about correct.” Where there is sub- 
jective pain, or itching, or sense of cramp, and the like, 
the limb is unceasingly felt, but in nearly all cases the 350 
INJURIES OF NERVES. 
most absurd mishaps occasionally remind a man at once 
of his loss, and of the obstinacy of the consciousness of 
the limb’s existence. The sufferer who has lost a leg gets 
up in the night to walk, or he tries to rub or scratch it. 
One of my cases attempted, when riding, to pick up his 
bridle with the lost hand, while he struck his horse with the 
other, and was reminded of his mistake by being thrown. 
Another person, for nearly a year, tried at every meal to 
pick up his fork, and was so disturbed emotionally at the 
result as frequently to be nauseated, or even to vomit. 
The site of the amputation does not seem to exercise 
any influence upon the consciousness of the existence of 
the limb, but in time, if not reminded by pain or other 
subjective symptom, the patient is apt to lose sense of the 
presence of the part, and this, I think, is most liable to 
occur as regards the leg. 
The limb is rarely felt as a whole; nearly always the 
foot/or the hand is the part more distinctly recognized, 
and, on careful questioning, we learn that the fingers and 
toes are readily perceived ; next to these the thumb; then 
more rarely the ankle or wrist; and, still less frequently, 
the elbow and knee. Very often some fingers are best 
felt, especially the forefinger. On the other hand, there 
is, in but few cases, any consciousness of the parts which 
intervene between' the stump and the extremity of the 
limb. The patients describe themselves as knowing that 
they have a hand which is connected to the stump, and 
feel able to move it, but of the rest of the limb they are 
unconscious, and the subjective sensations which are so 
common are always referred to the hand or foot, and 
rarely to the continuity of the member.* 
* These facts are not confined to lost limbs or parts of limbs. The 
amputated breast is often felt as if present, and the lost penis is subject to 
erections, of which Dr. Ruschenberger, TJ. S. N., has related to me a 
remarkable example. NEUIIAL MALADIES OF STUMPS. 
351 
Closely related to these facts is a curious symptom, 
which M. Gueniot (op. cit.) was the first to describe. In 
about one-third of the leg cases, and in one-half of the 
arm amputations, the patient asserts that the foot or hand, 
as the case may be, is felt to be nearer to the trunk than 
is the extremity of the other limb. The lost limb seems 
to be shortened. This is a sensation which, in many cases, 
is first felt within a week of the amputation, and goes on 
progressively, the hand, for instance, slowly approaching 
the stump. Very often the change is not noticed until 
attention is called to it, although usually the gradual alter- 
ation is recognized during its occurrence. The phantom 
hand at last reaches a point where it ceases to move, and 
this may be at almost any part of the intervening dis- 
tance which once separated it from the seat of operation. 
Sometimes it continues to approach the trunk until it 
touches the stump, or lies seemingly in its interior,—the 
shadow within the substance. 
We are competent in health, even with closed eyes, to 
know where and how far removed the hand may be at 
any moment, and this knowledge is the result of long-con- 
tinued and complicated sensory impressions, ocular, mus- 
cular, and tactile. Should we lose these by amputation, 
we cease to have consciousness of the extremity of a limb 
as set at any fixed distance. Such is very nearly the ex- 
planation which M. Gueniot offers in his interesting 
account of the delusion in question, but we fail to learn 
from him why, after losing sens'e of the distance of the 
hand or foot, these should seem to approach the stump. 
Wherefore, indeed, should they not appear to recede? 
Perhaps the following explanation may assist us to answer 
this question. To the lost hand alone are sensations re- 
ferred. There are none in the intervening portions of the 
lost limb, and the stump is the lowest visible point where 
pain or touch is felt; and therefore it is that the sensorium 352 
INJURIES OF NERVES. 
learns by degrees to associate in place the lost band, which 
seems to feel, with the stump, the latter being the lowest 
existent point impressions on which are referred to the 
hand. Now, we may conceive that if, for motor purposes, 
we substitute for the lost limb an artificial member which 
does not possess feeling, the sense of sight will soon 
refer, in our consciousness, the hand or foot to its old 
position. Exactly this is described as occurring by two 
observant and acute persons who have lost legs. One of 
them, who sees in his business capacity hundreds of the 
amputated every }Tear, assures me that his experience is 
a common one. He lost his leg at the age of eleven, and 
remembers that the foot by degrees approached, and at 
last reached, the knee. When he began to wearan artificial 
leg it reassumed, in time, its old position, and he is never, 
at present, aware of the leg as shortened, unless for some 
time he talks and thinks of the stump and of the missing 
leg, when, as happens in many who have submitted to 
amputation, the direction of attention to the part causes a 
feeling of discomfort, and the subjective sensation of active 
and unpleasant movement of the toes. With these feel- 
ings returns at once the delusion of the foot as being 
placed at the knee. 
Gueniot is of opinion that the hallucination as to the 
shortening of the limb is most apt to occur in cases of 
amputation which heal most kindly and offer the most 
healthy stumps. I have been unable to make out any 
such relation. 
Subjective sensations referred to the absent limb.—In a few 
cases there is no distinct subjective symptom to remind 
the patient of his limb, but in nearly all there is some 
feeling, such as pain, itching, or other sensation. 
I have found no one who ever had the subjective delu- 
sion of the lost part being touched; but itching is quite 
common, and is referred usually to the backs of the NEURAL MALADIES 0E STUMPS. 
353 
fingers, very rarely to the elbow, or, in the leg, to the 
arch of the foot. Many persons relieve this feeling by 
rubbing the stump; but others derive no benefit from 
this procedure. 
I have elsewhere spoken of the sensitiveness of stumps 
to heat and cold. Some men have no subjective sen- 
sation due to thermal changes in the stump; but about 
one-third complain of coldness in the lost part when the 
stump is chilled, and of heat in it when the stump is 
warm. I tested this by dipping arm-stumps in iced- 
water or water at one hundred degrees Fahrenheit, and 
found that a few men experience a subjective sensation of 
heat and cold, but of the rest more feel a sensation of 
referred cold than of heat, and there is often some confu- 
sion as to whether the missing part experiences cold or 
heat, or is merely painful. Perhaps in these cases, the 
knowledge of the fact that cold or heat is being used on 
the stump inclines the patient, in whom there is thus pro- 
duced any subjective impression, to consider it as heat or 
cold. I see no way of escape from this possible fallacy ; but 
some of my best witnesses are confident as to the fact that 
a cold or hot stump makes a cold or hot limb; and if so, it is 
interesting in a physiological point of view to know that 
thermal impressions on the ends of nerves or on their 
continuity may occasion like sensations referred to the 
ultimate distributions. I have known persons who suf- 
fered in hot weather frojn sense of heat in the lost hand, 
and were able to ease it by using cold to the stump. 
Subjective sensations as to motor 'phenomena in the lost limb.— 
The facts connected with subjective sensations of move- 
ment and as to delusions in regard to the position of the 
part are extremely curious. 
Position.—Impressions regarding the leg are far less 
vivid than those connected with the arm. The former 
limb when lost seems to hang straight, and there is usu- 354 
INJURIES OF NERVES. 
ally some difficulty in determining whether or not it 
swings with the motions of the body in walking. In only 
one case did it appear to be bent at the knee. 
In fourteen arm amputations at divers points, the arm 
seemed in two to hang at the side, and in seven to be 
bent, the hand lying in air a little way from the left breast 
or straight in front, and the hallucination as to position 
being insisted on even by those who declared themselves 
unconscious of the limb’s continuity. The remaining five 
felt the hand to be in the air, somewhere in front of the 
chest, but had no consciousness of flexion at the elbow. 
The posture of the lost hand may best be described by 
simply quoting a few of the descriptions given me by 
patients. In many it seems to be at rest, extended, the 
fingers in a like posture; and these cases have usually, or 
seem to themselves to have, the best power of voluntary 
movements. Others carry with them a hand in a state of 
more or less violent flexion, and possess but slight con- 
trol over it. Another class has the hand constantly in 
some painful position which it occupied before the opera- 
tion, so that the last real sensation is so stamped upon the 
sensorium as to forbid its erasure by any future impres- 
sion. We have realized here, in regard to common sensa- 
tion, the fable which describes the retina as retaining after 
death the last picture which fell upon its living concavity. 
These cases suffer horribly both from volitional efforts 
and from such faradisation of the nerves as causes sub- 
jective motor sensations. 
Mr. T. lost his arm five inches below the elbow at the 
age of six years, eighteen years ago. The arm appears to 
lie out from the side, the wrist flexed, the fingers semi- 
flexed; every voluntary effort causes intense pain in the 
stump; the hand seems to be at the elbow. 
J. II., aged forty-two, lost his right arm four inches 
above the elbowq twenty-four years ago. He feels the NEURAL MALADIES OF STUMPS. 
355 
presence of the whole limb more plainly than ever. The 
hand is described as half shut, the thumb standing out 
from the palm, the elbow and wrist half flexed. 
W. S. lost his right arm at the upper fourth, and the 
left at the lower third, eleven years ago. Is conscious of 
the left arm throughout, less of the right, but neither 
seems shortened. Both hang at the sides extended, but 
at night, after being in bed some time, both arms are felt 
as if lying over the head, and as if bent at the elbows. The 
hands are tightly clinched, the wrists violently flexed at 
times, while occasionally the hands open of themselves. 
E. C., aged thirty-two, lost his left arm five inches helow 
the shoulder, nine years ago. When shot, the thumb 
turned into the palm, and continued in this state of 
spasm, so that when, six hours later, the limb was re- 
moved, the nail of the thumb had cut into the palm. He 
several times lifted the thumb, but it always returned to 
the same place. For nine years the absent thumb still 
remains cutting into the palm. The coming of a storm 
makes the spasm more severe and causes the fingers to 
close over it. The limb seems shortened six inches. 
L. B., on account of a gunshot wound of the wrist, 
lost his forearm at the middle. He wears an artificial 
arm. He realizes the presence of the hand only. It is half 
flexed, hangs at his side, and is under full control of the 
will. The hand appears to be on the stump. 
C. T., aged sixty, lost his right arm twenty years ago. 
It wras crushed between two car buffers, and was taken 
off ten hours later. He wears no artificial arm. He 
feels the arm rather less distinctly than at first, but is 
more conscious of it than of the left arm. At present 
only the hand is perceived. It seems to lie in front of the 
chest pointing to the left, and is semi-flexed and capable 
of limited movement. 
II. H., aged twenty-seven. Three years ago the hand was 356 
INJURIES OF NERVES. 
crushed by rollers and removed at the middle of the fore- 
arm on the fourth day. He has no artificial limb. The 
hand is on the stump and tightly closed, the thumb over 
the fingers. 
B. B., aged fifty-two. The right hand was caught be- 
tween two hot rollers and dreadfully burned, but not 
severely crushed. It rested in rigid extension on a pillow 
for two weeks, and was then taken off five inches below 
the elbow; does not use an artificial arm. The hand is 
felt as lying in extension; the fingers rigid, just as they 
were before the amputation. He can slightly stir them, 
the muscles in the forearm acting visibly, and the attempt 
causing pain. Efforts to move the intrinsic muscles of 
the hand also occasion pain, but he has very little con- 
sciousness of motion in the lost part, although the 
muscles of the stump act freely. 
J. K., aged forty-four, has had his leg amputated thrice: 
once below the knee, once above it, and finally at the 
upper third of the thigh,—all fourteen years ago. The 
sensation of the presence of the toes, and rarely of the 
heel, continued throughout, but has of late lessened, so 
that unless the stump has been hurt he does not feel fully 
conscious of the lost parts. 
A. M., aged twenty-four, had his right hand injured by 
the discharge of a cannon. Has no artificial limb. Am- 
putation was performed two inches below the elbow; the 
stump is very tender, the hand seems half way up the 
arm, the fingers are shut, the thumb lying over them. 
Can stir the thumb, but not the fingers. 
J. C., aged thirty-one, received a wound in the elbow, 
for which amputation at the lower third of the arm was 
performed four hours later. The stump is healthy; it has 
no artificial arm. The lost hand lies seemingly in the 
stump. He is most conscious of the index and medius 
fingers, which are always painful and intensely cramped; 
there is no perception of the wrist or elbow. NEURAL MALADIES OF STUMPS. 
357 
The lost limb, and especially the arm, is usually found 
to follow the movements of the stump, whether these be 
passive or active, while in some instances it never leaves 
its place, or else there is only a vague sense of its com- 
mon position having been disturbed. 
Involuntary movements of the absent toes or fingers are 
frequent, and in very many persons are unfailing precur- 
sors of an east wind. Sometimes only one finger is thus 
active, or the digits flex one after another, and then slowly 
extend, while wrist movements are exceptionally rare, and 
the elbow and knee are never felt to change place at all. 
Leaving out of the question cases which have no sense 
of the presence of a lost limb, we find that in a very 
small number there is no consciousness of power to stir 
any part of the absent members by force of will. All 
others are able to will a movement, and apparently to 
themselves to execute it more or less effectively, although 
in most of the amputated such phantom motions are con- 
fined to the fingers or toes, which rarely seem to possess 
the normal range either of flexion or extension. Yet the 
certainty with which these patients describe the limita- 
tions of motion, and their confidence as to the place 
assumed by the parts moved, are truly remarkable; while 
these restricted movements are pretty surely painful, and 
the effort is apt to excite twitching in the stump. 
A small number have entire and painless freedom of 
motion as regards all parts of the hand. “ My hand is 
now open, or it is shut,” they say. “ I touch the thumb 
with the little finger.” “ The hand is now in the writing 
position,” etc. Between these cases and such as are con- 
scious of an immobile member, every grade of difference 
as to motion is to be found, with equally wide varieties as 
to the associated pain, which perhaps is most acute in 
such as will with vigor a motion that they seem to fail of 
executing. 358 
INJURIES OF NERVES. 
In some of these cases, as in forearm amputations low 
down, the muscles which chiefly move the fingers are 
present, wholly or in part, and move readily under voli- 
tional impulses, so that whatever knowledge of move- 
ments comes to the sensorium through the muscles moved 
is here not wanting. 
In others, as in shoulder-joint cases or amputations 
through the humerus, the muscles which act on the hand 
are absent altogether; yet in these there is fully as clear 
and definite a consciousness of the movement of the 
fingers and of their change of positions as in the former 
cases. In other words, the volition to move certain parts 
is accompanied by a mental condition which represents 
to the consciousness the amount of motion, its force and 
ideas of the change of place in the parts so willed to move. 
The physiology of the day accepts the belief that all 
of our accurate notions as to the amount of power put 
forth, and as to the parts thus stirred, reach the sensorium 
from the muscles acted on and the parts moved. It 
would appear, however, from the statements here made, 
as if coevally with the willing of a motion there came to 
the consciousness, perhaps from the spinal ganglia acted 
upon, some information as to these points. If, in reply 
to this, I be told that the constancy of long habit may 
have associated memorially with certain ganglionic’activi- 
ties the ideas of local movements, I should hardly feel 
that this was an answer, because in some of my cases the 
amputations took place so early in life that there was 
no remembrance of the lost limb, and yet twenty years 
after, a volition directed to the hand seemed to cause 
movement which appeared to be as capable of definite 
regulation, and was as plainly felt to occur as if it had 
been the other arm which was moved. Probably, then, a 
part of those ideas which we are presumed to obtain 
through the muscular sense are really coincident with, NEURAL MALADIES OF STUMPS. 
359 
and necessitated by, the originative act of will, or else are 
messages sent to the sensorium from the spinal ganglia 
which every act of motor volition excites. 
The influence of electrical currents on the nerves of 
the stump introduces into our calculations certain novel 
and puzzling considerations. 
If we faradise the track of the nerves in or above the 
stump, we may cause the lost fingers and thumb to seem 
to be flexed or extended, and, what is most remarkable, 
parts of which the man is conscious, but which he has not 
tried to stir for years, may thus be made to appear to 
move to his utter amazement. In one case I thus acted 
on the nerves, so as to cause a thumb which for years 
was constantly and violently bent in on the palm to 
straighten out completely. On breaking the circuit, 
without warning, the patient exclaimed that his thumb 
was cutting the palm again, and the same result was ob- 
tained by shifting the conductors so as to put the nerves 
out of the circuit. 
In a case of amputation at the shoulder-joint, in which 
all consciousness of the limb had long since vanished, I 
suddenly faradised the brachial plexus, when the patient 
said at once, “ My hand is there again. It is bent all up 
and hurts me.” These impressions are correctly referred 
by the patient, so that faradisation of the musculo-spiral 
or the ulnar gives sensation of movement in the related 
parts. It is of course impossible that the motor nerves 
stimulated should convey any impression centrally, and 
we must therefore conclude that irritation of sensory 
trunks may occasion impressions of muscular motion in 
the sensorium. 
It would appear, then, that when we will a movement, 
there arises coincidently, or from the spinal ganglia 
through which it is carried out, impressions as to the 
force of the act and the position of the parts which we 360 
INJURIES OF NERVES. 
will to move; so that given the volition, there springs up 
in the mind a consciousness as to the act and its qualities, 
which is too generally believed to originate altogether 
from the external parts disturbed. On the other hand, 
the second series of experiments proves, or makes proba- 
ble, that certain nerves carry centrally, during motion, 
impressions which, with those nascent in the centres 
when the act is willed, go to complete the general knowl- 
edge as to motor activities. The subject admits of much 
further study and of other inferences, which, however, 
are scarcely entitled to a place here, but are related in an 
interesting way to the group of ataxial diseases. 
Neuralgia of stumps.—I have elsewhere said that many 
stumps are extremely sensitive, and this is especially true 
of the arm. In these cases it will almost always be found, 
upon careful examination, that certain nerves are enlarged, 
hardened, and tender. I have relieved a number of such 
cases by cold, by repeated leeching, and by general irrita- 
tion of the surface of the stump. 
Acute neuralgia of stumps is happily more rare. It 
sometimes follows the operation closely, or is brought on 
by a blow or by more occult causes. In one case it came 
on during an attack of acute rheumatism; in another 
from an influenza; and I have seen two instances where a 
sudden spasmodic motion of the arm-stump was followed 
at once by intense pain, and seemed to be the starting- 
point of an attack of neuritis. One of these cases I saw 
with Dr. Packard. It yielded to leeches and hot fomen- 
tations after much torment. So far, indeed, as my own 
experience goes, old stump neuralgias never exist without 
a sclerotic state of the nerve,—originating, I presume, 
in neuritis, and tending without fail to progress centrally. 
The rules for treating neuritis of course apply here, and 
every care should be taken to deal early and boldly with 
indications of neural pain in stumps. NEURAL MALADIES OF STUMPS. 
361 
The torture endured in some of these cases must be 
extreme. The pain is often unceasing, and is usually- 
referred to the lost limb, or, as the case progresses, to 
the stump itself; while in some curious instances, as in 
Nott’s case, it is never felt or referred below this point. 
The aching and shooting pains are finally complicated 
by excessive hypersesthesia of the stump, with all the 
mental and moral consequences which prolonged and 
constant pain engenders. Opiates in excess become at 
last the only comfort, and even these may fail to give 
entire relief. 
I have treated several of the moderately severe forms 
of this disease. All of them were removed by months or 
years from the date of operation. In four, which were arm 
cases, one below and three above the elbow, the nerves 
were exquisitely tender and enlarged for some distance 
above the stump. In another patient, they were tender 
but not perceptibly larger. One case I failed to relieve, 
and he declined an operation. Three others were success- 
fully treated by leeches at intervals, with hypodermic 
injections of morphia and atropia, and large, warm poul- 
tices, applied constantly. One proved obstinate, yet 
was relieved, but not quite completely, by a short 
mercurial course, mercurial ointment being used over the 
arm-stump and axilla until slight salivation took place. 
The gain was permanent, but was not so great as in the 
other instances. I have seen no example of the terri- 
ble forms of this disease which some authors describe, 
and which require section of nerves or reamputation for 
their relief. The history of such operations is by no 
means encouraging, and too often one operation follows 
another without permanent help to the patient. The 
reason for these failures lies in the fact that the disease 
of the nerve passes gradually upward, and that an opera- 
tion, being unfortunately looked upon as a last resort, is 362 
INJURIES OF NERVES. 
put off'until by degrees the whole nerve trunk is so com- 
pletely involved that there remains no healthy portion of 
nerve in which to perform neurotomy; while to leave any 
of the sclerotic nerve above the line of section is only to 
make probable future suffering. 
Whatever hesitation as to nerve section may be reason- 
able in other cases, there should be but little as regards 
stumps: first, because delay is apt to make useless any 
operation; and secondly, because division of nerves in 
stumps is productive of so little loss of valuable function. 
When, then, the pain is intense and lasting, and does not 
readily yield, and the nerve trunks are tender, I should 
strongly advise an early resection of the nerve as high 
up the limb as possible. 
The operation should be such as to provide against re- 
union, by means already described ;* and if on microscopic 
examination of the exsected portion of nerve it prove to 
be diseased, it would be advisable at once to divide it 
still higher; or if this be impossible, the central part 
of the nerve should be actively treated by leeching, by 
counter-irritants, and, perhaps, by cold. 
Large numbers of operations for the relief of stump 
neuralgia have failed because of attempts to remove only 
the button-like enlargements at the ends of the nerves, 
under the impression, not always erroneous, that in these 
growths lies the cause of mischief. I fancy these, how- 
ever, to be but rarely the cause of trouble, and the 
opinion is mischievous, because it postpones a more 
radical operation. 
Dr. Nott’s case, which I have elsewhere related,! is a 
good example of progressive neuritis extending toward 
the centres, consequent neuralgia, and mischievous delay 
* See Neurotomy, p. 282. 
f See p. 240, Treatment. NEURAL MALADIES OF STUMPS. 
363 
in performing the operation for relief early enough and 
tar enough up the limb. 
Chorea of stumps.—I find nowhere any detailed account 
of the disease which, for lack of a better name, I have 
called chorea of the stump. The muscles of stumps, of 
arm-stumps especially, are constantly in what I might 
call a condition of unstable equilibrium, liable to act 
irregularly under volition, or to contract spasmodically 
from emotion or from changes in the weather. The 
mere act of thinking of the lost limb, or the concentra- 
tion of attention upon the stump, will, in many, suffice 
to excite tremor, irregular brief contractions, or cramp; 
while in some persons quite violent spasms occur with- 
out any assignable cause. 
The stump muscles or nerves are in the condition of 
those of a person fully charged with strychnia, ready to 
respond excessively and without regularity to every exci- 
tation, and this is especially true of irritable stumps on 
which no artificial limb can be worm Owing to this state of 
excitability, it is easy in many stumps to cause twitching, 
or still freer movement, by rolling the nerves under the 
compressing finger, or by pushing them aside, and then 
suddenly releasing them, vibrating them, so to speak. 
These nerves are in just such a state as may be brought 
about artificially in a healthy nerve by chilling it with 
ice, when the least tap will occasion sudden spasm. No 
wonder, then, that more permanent spastic affections of 
stumps are occasionally met with. 
I have myself seen and treated but two instances of well- 
marked choreoid disease, although through other physi- 
cians I have had partial experience of a number of cases. 
Case 67.—I. 0. suffered amputation of the left arm, in 
Georgia, in 1863, for a wound of the forearm. I examined 
him once, a year later, and have not heard of him since. 
While the stump was yet unhealed, in the fifth week, the 364 
INJURIES OF NERVES. 
biceps began to twitch, and finally union was only attained 
by bandaging the limb firmly. From that time the arm 
was constantly subject to spasms, which jerked it forward 
with clocklike regularity and with great force. When 
an effort was made to secure the stump to his side, the 
movements attacked the shoulder, but ceased when the 
stump was set free. There was also slight twitching of 
the left facial muscles, and occasionally some irregu- 
larity in the vocal muscles, causing him to speak with 
difficulty. The general health was good, but memory 
was defective, and the man, who was a mendicant, was 
unwilling to take the chance of relief which division of 
the neural supply of the biceps seemed to offer. The 
motions ceased at night. I understood that he had 
had a great variety of fruitless treatment, and his arm 
showed signs of some of it. The following case was 
more satisfactory as a history. I have already had occa- 
sion to allude to it. 
Case 68.— Gunshot wound of right wrist; immediate ampu- 
tation ; choreal affection of muscles of the stump of the right 
forearm and of the shoulder. Colonel J. G. P.,agcd forty- 
one, 139th Pennsylvania Volunteers, an officer of high 
character, in good health up to the date of wound, was 
shot, June 3, 1864, through the right wrist with a slug. 
He became at once singularly excited, and felt as if he 
were crazed. Under the sudden influence of these sen- 
sations, he ran along the line of his regiment, only half 
conscious, until he fell senseless, having gone about fifty 
feet. Within a few minutes he revived, and was assisted 
to a hospital near by, where Dr. Chapin, surgeon of the 
regiment, amputated his forearm at the junction of the 
lower and middle thirds. 
Colonel P. never remained in bed, but continued in 
active service while the wound healed. This process was 
over about September 20, 1864. At this date some one NEURAL MALADIES OF STUMPS. 
365 
remarked to him that his stump shook a good deal, thus 
first attracting his attention to the spasmodic motions. 
Within a month the quivering extended to all the muscles 
of the forearm, except the extensor group, and at the 
close of the second month it attacked the biceps, triceps, 
and deltoid. In November, a seton was carried through 
the skin of the stump. For a day or two the limb was 
much more quiet, but again became worse. Tincture of 
aconite was used locally without relief. A firm bandage 
applied to the whole limb produced no good result, the 
movements getting constantly worse. At length a large 
part of the cicatrix of the stump was dissected out. For 
a few days he did better, and then relapsed, as happened 
after the use of other remedies. 
March 1, 1865.—The forearm is incessantly in motion, 
the muscles quivering in a singular manner, night and 
day, whether asleep or awake. Every twenty seconds, or 
oftener, the forearm is suddenly flexed, and more rarely 
the arm is thrown across the chest by the pectoral group, 
or upward and outward by the deltoid. These move- 
ments are beginning to involve the trunk and neck mus- 
cles of the right side. They are increased if attention 
be drawn to them, but they still allow him to make 
regular voluntary movements, and do not seem to in- 
terfere with or disturb this volitional control, as hap- 
pens in the chorea of children. The moment his will 
ceases to act, the spasms recur, but he does not feel 
any fatigue from this endless muscular. action. All 
the muscles move readily under induced electric cur- 
rents. The stump is not unusually tender, and there is 
no soreness in the nerve tracks when tested by heat or 
pressure. Colonel P.’s general health is suffering some- 
what, but at no time, except during the few days of leave 
which he sought in order to consult me, has he failed to 
do duty in the field. On one occasion only is he aware 366 
INJURIES OF NERVES. 
that the arm ceased to move. This occurred at the battle 
of Cedar Mountain, when, his regiment having been cut 
off, he was in grave danger of capture. He fought his 
way out and saved his command. During the two or 
three hours of suspense, and while constantly under fire, 
his men observed that his arm ceased to move, and hung 
motionless at his side. 
I felt strongly disposed to consider these movements as 
caused by some nerve lesion originally confined to the 
stump, and occasioning in the centres an excitation which 
gave rise reflectively to the spasms. To test this, I pro- 
posed to inject a paralyzing agent into the neighborhood 
of the main nerve trunks, and failing thus to check tho 
conveyance of irritations to the centres, I should have 
wished to divide the chief nerves in the arm. This, of 
course, would have paralyzed the lower muscles con- 
cerned. If, then, it were found that the deltoid and 
pectoralis still twitched, I should have concluded that the 
nerves were diseased above the point of section; and as to 
this, some judgment could have been formed by examin- 
ing with the microscope the portion of nerve removed by 
the knife. After this there would have been no surgical 
remedy, excepting section of the brachial plexus in the 
neck,—an operation which, I presume, might offer some 
embarrassments. 
As Colonel P. was obliged to return to duty at once, I 
contented myself with ordering him to have two setons 
carried through the stump, and to take increasing doses 
of bromide of potassium thrice daily. 
He was severely wounded in the left side, March 25th, 
1865, and lay insensible for some time, although the limb 
all the while twitched as usual. He recovered readily, and, 
under date of April 17th, wrote that the limb had ceased 
to jump as freely as it had done, but was never quite still. 
I saw Colonel P. again, September 29. The arm, at this NEURAL MALADIES OF STUMPS. 
367 
time, rarely executed any violent or wide movements; 
but the forearm was much the same as his letter described 
it to have been in April. A greater gain was visible in 
the chest, neck, and trunk, the muscles of which no longer 
twitched. His general health was better, and he had 
become quite robust. I desired him to renew the treat- 
ment as soon as he was at rest in any one place, and 
hoped to persuade him at a future period to allow of 
some such operation as I have alluded to above. 
I have heard of Colonel P. very recently, and learned 
that he has still the same movements, but is otherwise 
in perfect health. 
‘*1 alluded in the medical volume of “Sanitary Reports” 
to a case of chorea following amputation of the thumb, 
but have, unfortunately, no notes of it. The choreoid 
motions extended from the intrinsic thumb muscles to 
the arm and shoulder, and after a year or more became 
limited again to the forearm. The patient was cauterized, 
blistered, treated by setons, and by an endless variety of 
drugs, without avail. 
Full doses of the bromides seemed to be of some use 
in Colonel P.’s case. In the localized chorea of adults, I 
cannot boast of success with these drugs, with any form 
of electricity, or with other means of treatment, and there 
seems to me to be much resemblance between these cases 
and the no less persistent form of chorea in stumps. 
To this obstinacy in the face of all therapeutic inter- 
ference I can make but one exception. An officer had 
incessant movement of the biceps muscle of an arm- 
stump. The spasm was annoying, but rarely violent, and 
was limited to the upper two-thirds of the muscle, the 
line of amputation having passed through it. In this 
case, daily injections of atropia (-fa to -jV grain) into the 
mass of the muscle, entirely relieved him after nearly 
twenty such applications. 368 
INJURIES OF NERVES. 
I think that it would be justifiable in these cases to 
divide the nerves concerned in the motions; but I should 
feel cautious and anxious about any such operation, 
having seen two instances in which operations for other 
causes proved fatal in adult chorea. 
Choreal spasms with neuralgia.—There are also examples 
of chorea in stumps associated with intense pain, and it 
is not uncommon to find that in certain persons the rare 
spasmodic movements of stump muscles are accompanied 
by neuralgic paroxysms, just as happens in certain facial 
tics, and more rarely in such instances of general neural- 
gia as I have described elsewhere.* 
A distressing example of this combination is related 
by Mr. Langstaif.f The forearm of a woman was re- 
moved on account of neuralgia from injury, and, healing 
with difficulty, there ensued a constant state of convul- 
sive action in the stump muscles with agonizing pain. 
A great variety of treatment failed to relieve her. The 
skin over the bones was red and sore, the arteries beat 
with extreme violence, frequent convulsive fits followed, 
and her general health gave way. The limb was finally 
reamputated above the elbow, when the nerves were 
found to be greatly enlarged and to end in the stump in 
the usual button-like growths. Entire and continued 
relief was obtained by the operation. 
* Reports of Philadelphia College of Physicians, 1869. 
f Med.-Chir. Trans., v. xvi. p. 140. INDEX. 
Abernetiiy, lancet wounds of 
nerves, 89. 
Acupuncture, 268. 
iEsthesiometer, 188. 
difficulties in using, 183. 
Agnew, D. H., pressure by bursal 
sac, 122. 
dislocation causing palsy of 
arm, 102. 
exsection of ulnar, 296. 
Alison, Scott, hemiplegic arthritis, 
169. 
Althaus, brachial palsy, 128. 
Amounts of nerve injury, how 
learned, 83. 
Amputations, 346. 
delusions as to motion follow- 
ing, 357, 358, 3o9. 
delusions as to place of lost 
limb after, 353, 354, 355, 356. 
for neural pain, 285. 
functional changes after, 342. 
lost parts felt after, 350. 
sensory delusions after, 348. 
Anaesthesia, 181. 
electrical treatment of, 249. 
Analgesia without anaesthesia, 192. 
Anatomy of nerves, 13. 
Aneurisms, pressure on nerves by, 
120, 121. 
Annandale on glossy skin, 159. 
Anomalies in nerves, 241. 
Arloing and Tripier, 239. 
Arsenic useless in traumatic neu- 
ralgia, 280. 
Arthropathies, 169. 
from central lesion, 259. 
Atrophy of skin, 155. 
muscular, pathology of, 150. 
with contraction, 206, 252. 
Atropia in spasm, 258. 
used with morphia, 271. 
useless in traumatic pain, 270. 
Autogenesis of nerve not proved for 
man, 85. 
Autogenetic repair of nerves, 80. 
Axis, cylinder, 17. 
Bachon, palsy from malposition 
when drunk, 130. 
pressure of water vessels causing 
palsy, 132. 
Ball, cause of rheumatism, 169. 
Banks, W. M., wounds of digital 
nerves, 91. 
Barensprung on herpes, 35. 
Bastien and V ulpian, results of press- 
ure on nerves, 108. 
Batteries, 248, 249. 
Beale on terminations of nerves in 
skin, 18. 
nerve endings in muscle, 21, 22. 
Becquerel, disks of, 174. 
Bellingeri, hair changes from nerve 
wounds, 164. 
Berard, case, 92. 
Bernuilly, tumor of pelvis causing 
palsy, 126. 
Bert on grafting of tissues, 47. 
Bianchi, palsy, in delivery, 123. 
Bigelow, H. J., rhigolene, 57. 
Blisters in causalgia, 273. 
Brinton, J. H., pressure of rein 
causing palsy, 131. 
Brown-Sequard on trophic nerves, 
34. 
Bullae, from nerve wound, 154. 
Burning pain, 196. 
influence on health, 198. 
( 369 ) 370 
INDEX. 
Burning pain, seat of, 196. 
theory of, 199. 
Callender on fractures causing nerve 
injury, 106. 
Callus, pressure from, 116. 
with inflamed nerves, 120. 
Calorification, effect on of nerve 
injuries, 173. 
Cancer, pressure on nerves by, 120. 
Case of nerve wound from bone 
splinter, 106. 
of arthritic lesions from nerve 
wound, 171. 
of arthropathies from lesion of 
spine, 259. 
of brachial palsy from dislo- 
cated humerus, 101. 
of cancer pressing on nerves, 
120. 
of causalgia, 199, 273, 278. 
of causalgia, amputation, 295. 
of chorea of stump, 363, 364. 
of compression by callus, 117. 
of contusion of ankle, 209. 
of contusion of brachial plexus, 
96. 
of contusion of median, 96. 
of contusion of musculo-spiral, 
230. 
of contusion of ulnar, 95, 312. 
of crutch palsy, 133. 
of early return of function after 
nerve wound, 138 
of epilepsy from sclerosis of 
nerves, 70. 
of exsection, median and ulnar, 
292. 
of axillary nerves, 302. 
of ext. ant. thoracic. 314. 
of facial, 327, 329, 331, 333, 338. 
of facial palsy, 128. 
of glossy skin, 159. 
of glossy skin from central 
lesion, 160. 
of hypertrophy from nerve 
lesion, 167. 
of injury of ulnar, exsection, 
295. 
of left hypoglossal nerve, 335. 
of median, 165. 
of median exsection, 298. 
of median and ulnar, 209, 207. 
of musculo-spiral nerve, 189. 
of nerves of tongue, 216. 
Case of neuritis, 63, 64, 65, 311. 
of palsy from sleeping on arm, 
129, 130. 
of palsy of extensors from dis- 
location, 103. 
of post-partum paralysis, 125. 
of sciatic, 308, 309. 
of sclerosis of nerve, 285. 
of section of median, 85, 240. 
of section of ulnar and median, 
252. 
of Swan, nerve wound from lan- 
cet, 90. 
of sympathetic, 318. 
of tonic spasm, 304. 
of typhlitis affecting sciatic, 
221. 
of Verneuil, callus pressure, 
119. 
of wound of anterior external 
thoracic, 211. 
of wound of facial nerve, 325. 
of wrist, 307. 
Causalgia, 272. 
blisters in, 273. 
treatment of, 266. 
Causard, cases of contusion, 95. 
injury from dislocations, 99. 
Causes of nerve injury in disloca- 
tions, 100. 
Cerebral palsy, diagnosis of, 222. 
Charcot, arthropathies, 169. 
bullae from nerve injury, 154. 
Chassaignac, position of nerves as 
protecting, 29. 
Chiasms in birds and reptiles, 28. 
Yulpian on, 27. 
Chorea, 148. 
Chorea and neuralgia in stumps, 
368. 
Chorea of stumps, 363. 
checked by emotion, 347. 
treatment of, 367. 
Cicatrices, pressure from, 115. 
Clavicle, fracture of, causing palsy, 
105. 
Claw-hand, 255, 256. 
Cold, drv, in pain, 272. 
Cold, effect of on stumps, 345. 
effect on nerves, 54. 
in neuralgia, 267. 
Compression of nerves, 107. 
during labor, 123. 
Compression, treatment of, 229- 
Conductors, use of, 247. INDEX. 
371 
Congestion, artificial, of nerves, 57. 
Congestion of nerves, 56. 
■ results of, 57, 58, 59. 
Conia, use of, in neuralgia, 270. 
Connective tissues, trophic change 
in, 166. 
Contracting muscles, 206. 
Contractions, 256. 
Contusion of nerves, 92. 
results of, 94. 
symptoms of, 94. 
treatment of, 229. 
Counter-irritation, 266. 
in neuralgia, 267. 
Crampton, increase of hair from 
neuritis, 164. 
Crutch palsy, 132. 
Cylinder axis, persistence of, after 
section, 77. 
Danielson and Boeck, 116. 
Daturia, use of in neuralgia, 270. 
Day on neuro-traumatic rheuma- 
tism, 168. 
on spinal rheumatism, 168. 
Defects of sensation, 181. 
Deformities from muscle changes, 
251. 
relation of, to motion, 207. 
Degeneration of nerves, 73. 
of divided nerves in animals, 
11. 
Delusions as to lost limb, 350. 
Denmark on glossy skin, 155. 
Desault on injury from dislocation, 
98. 
Descot, contusion, 95. 
Diagnosis, 213. 
of acute neuritis, 66. 
of local nerve lesions, 222. 
Dubreuihl on inflamed nerves, 61. 
Duchenne, 245, 317. 
loss of irritability, 244. 
treatment of anaesthesia, 249. 
trophic nerves, 35. 
dislocations, 98. 
Earle, brachial palsy from fracture, 
105. 
neuro-traumatic eruptions, 154. 
Eckhardt on nerve irritants, chemi- 
cal, 49. 
Eczema, neuro-traumatic, 155. 
Eczema with glossy skin, 158. 
Electric brush, 187. 
Electricity, 246. 
a test of loss of function, 244. 
early use of, in nerve wounds, 
246. 
form of current, 246. 
influence of on stump nerves, 
349. 
in prognosis, 227. 
in diagnosis, 220. 
in arthropathy, 259. 
mode of using, 248. 
Emboli, pain from, 52. 
Empis, cause of injury in disloca- 
tions, 100. 
Erichsen, temperature after nerve 
lesion, 174. 
Eruptions, cutaneous, following 
nerve wounds, 153. 
Eulenberg and Londois, nerve 
suture, 242. * 
Facial nerve, wounds of deep in ear, 
324. 
Facial nerve wounds, symptoms of, 
323. 
Facial palsy in child, from delivery, 
127. 
Faeces, accumulation of, a rare cause 
of palsy, 126. 
Faradisation in anaesthesia, 265. 
of stump nerves, 359. 
Femur, nerve injuries from its frac- 
tures rare, 106. 
Ferreol-Reuillet, nerve wounds from 
fractures, 104. 
Flaubert, nerves injured by disloca- 
tions, 98. 
Forceps, pressure by, causing palsy, 
127. 
Fractures of bones causing palsy, 
104. 
Freezing of nerves, 58. 
congestion which follows, 59 
thermal symptoms in, 60, 177. 
Fromman and Grandry, structure 
of nerve fibres, 17. 
Galli, tubes of, 242. 
Galvanism, 246. 
Glossy skin, 156. 
Morehouse and Keen on, 157. 
seats of, 158. 
Granger, fractures causing palsy, 
104. 372 
INDEX. 
Gross, S. D., incontinence of urine 
after amputation, 346. 
Gueniot, incontinence of urine after 
arm amputation, 347. 
lost parts, 
351, 352. 
Gull on shock, 142. 
Gurlt on pressure from callus, 118. 
Hager and Cohnheim, nerves of 
cornea, 19. 
Hair, changes in, from neuritis, 164. 
changes of, from nerve lesions, 
163. 
loss of, after nerve wounds, 164. 
fragility of, in some nerve 
wounds, 164. 
Hamilton, contusion of nerves, 95. 
Hamilton, seat of nerve wounds, 83. 
Hamilton, Jr., lancet wounds of 
nerves, 89. 
Hammond, W. A., hospitals organ- 
ized by, 10. 
Heat, effect of on stumps, 345. 
Herpes, 153. 
due to disease of ganglia, 36. 
from nerve injury, 153. 
Hilton, callus, pressure from, 118. 
on protections of nerves, 29. 
Hvoscyamus, use of in neuralgia, 
270. 
Hyperesthesia, 179. 
causes of, 180. 
from freezing of nerves, 180. 
remote from wound, 180. 
with causalgia, 181. 
Hypertrophy from nerve lesion, 167. 
Hypodermic injections in neuralgia, 
268, 269, 270. 
Hutchinson, neuro-traumatic erup- 
tions, 154. 
nerve wounds, 84, 86. 
thermal changes in nerve 
wounds, 174. 
Ice, in neuritis, 72, 73. 
Incised wounds, treatment, 234. 
Inflammation of nerves, effect of, 
234. 
Inflamed nerves, treatment of, 71. 
Injections, hypodermic, site of, 271. 
Injuries of nerves, varieties of, 82 
Introductory, 9. 
Irritability, loss of, 245. 
Jaccoud on shock, 142. 
Joints, disease of, from nerve 
wounds, 170. 
influence of nerve lesions on, 
168. 
treatment of disease of, 258. 
Keen, W. W., 245. 
case, 278 
case of palsy from pelvic frac- 
ture, lo7. 
causalgia, temperature in, 175. 
• on structure of cylinder axis, 17. 
Krause, 241. 
corpuscles of, 19, 20. 
and Kiibne, nerve endings in 
muscle, 21, 22. 
Kuhl, neuro-traumatic eruptions, 
154. 
Kiihne, chemical irritation of 
nerves, 49. 
f 
Labor, palsy from, causes of, 123, 
124. 
Landouzy, forceps-pressure a cause 
of palsy, 127. 
Langerhaus, terminations of nerves, 
19. 
Langstaff, choreal neuralgia of 
stumps, 368. 
Laugier, case of nerve suture, 238. 
Laverran, changes in divided nerves, 
74, 75. 
Leprosy of Norway, nerve disease 
from, 116. 
Leudet and Delaboit, functions re- 
tained after nerve section, 239. 
Ligature of vessels, pain from, 52. 
Lister on sympathetic nerves of 
frog, 32. 
Locality, sense of, 185. 
Londe, proportion of nerve wounds 
in various regions, 83. 
Loss of, thermal sense, 192. 
Magnien, date of reunion of nerves, 
235. 
Malaria, relations of to traumatic 
pain, 280. 
Malgaigne on neurotomy, 284. 
Malposition in sleep, palsy from, 
128. 
Manipulation, 249. 
use of, in pain, 271. 
Massage, 249. INDEX. 
373 
Massage, method of using, 250. 
Meissner, corpuscles of, 19. 
Mitchell, J. K., neuro-traumatic 
rheumatism, 168. 
Morehouse on chiasms, 27. 
Morphia and atropia, antagonism 
of, 271. 
Morphia, use of in causalgia, 272. 
in pain, 270. 
Morton, T. G., amputation for caus- 
algia, 287. 
Morton, T. G., case, 295. 
Motion, loss of in nerve wounds, 
treatment of, 245. 
Mougeot, changes of hair in nerve 
lesions, 168. 
Muscle changes after nerve section, 
150. 
deformities from, 251. 
Muscles, contraction of, 151. 
effects of nerve injuries on, 202. 
hyperaesthesia of, 181. 
of, 2S2. 
tonic contraction of, 202. 
Muscular sense, 358. 
Nails, alterations of, in nerve 
wounds, 161. 
curved, 162. 
blood effused under, in nerve 
lesion, 165. 
growth of, after nerve wounds, 
163. 
lessened growth of, in cerebral 
palsy, 223. 
non-growth of, in cerebral palsy, 
169. 
Narcotics, 268. 
Naudorfer, 240. 
Nelaton, case, 327. 
results of dislocations, 100. 
rapid repair of nerves, 327. 
Nerve, facial, wounds of, cases, 325, 
327, 329, 333, 351. 
fifth, wound of, 338. 
hypoglossal, wound of, 37, 355. 
Nerve wounds, atrophic states of 
skin in, 155. 
bullae following, 154. 
by bullets, treatment, 234. 
causing joint disease, 170. 
diagnosis of, 213. 
effect of, on connective tissues, 
166. 
on skin, 152. 
Nerve wounds, immediate local 
symptoms, 135.' 
influence of on muscles, 202. 
nail changes in, 161. 
not always productive of palsy, 
220. 
palsy from, 205. 
partial prognosis in, 225. 
secretions in, 172. 
suture in, 235. 
trophic changes in skin from, 
152. 
Nerves, action of acids on, 50. 
action of glycerine on, 50. 
autogenetic restoration of, 80. 
►changes after section, 75. 
congestion of, 56. 
contusion of, 92. 
contusion of, experiments on,93. 
degeneration of, 73. 
digital, wounds of, 91. 
direct lesion of, 82. 
distribution of fibres of sense 
and motion in, 26. 
►division of, 26. 
drying of, 51. 
effect of cold on, 54. 
fibres of, anatomy of, 16. 
freezing of, 177. 
how guarded from disease, 25. 
how injured, 82. 
hyperaesthesia from wounds of, 
179. 
incised wounds of, 83. 
injured by dislocation, 97, 99. 
injury of, in fractures, 104. 
irritants affect whole length 
of, 48. 
irritants of, chemical, 49. 
lesions of, physiological patho- 
logy of, 56. 
lesions of, symptomatology, 135. 
lesions, site of, 82. 
loops of, Hyrtl on, 27. 
of frogs, do not carry impres- 
sions over middle line, 28. 
of nerve sheaths, 15. 
of pain, 39. 
of stumps, diseases of, 342. 
of touch, corpuscles of, 241. 
of touch and pain, if separate, 
192. 
physiological pathology of, 56. 
pressure on, 107. 
protection of, 22. 374 
INDEX. 
Nerves, puncture of, 232. 
puncture of, pathology, 92. 
punctured wounds of, 92. 
recurrent, 27. 
relation of to bones, 25. 
repair of, 79. 
Eouget on, 21. 
section of, prognosis, 226. 
sections of, amount of possible 
repair after, 80. 
stimulants of, 49. 
strength of, experiments on, 24. 
stretching of, as influencing 
function, 24. 
structure of, 13. 
superficial wounds of, 88. 
sutures of, 237, 238. 
-—symptoms following wounds of, 
when small, 89. 
terminations of, in muscles, 21. 
—“trophic, 31. 
tubes of, relation to centres, 18. 
uses of elasticity of, 25. 
variation of normal pressures 
on, 53. 
varieties of, 30. 
various causes of pressure-palsy, 
131. 
water on, 50. 
Nervi nervorum, 15. 
Neural maladies of stumps, 343. 
Neuralgia, 360. 
dry cold in, 267. 
of stump, treatment of, 361. 
neurotomy in, 362. 
.traumatic, constitutional treat- 
ment of, 281. 
traumatic, statistics of opera- 
tions for, 288. 
treatment of, 267. 
with chorea of stumps, 368. 
Neurilemma, 14. 
vessels of, 15. 
Neuritis, 61. 
abscess from, 61. 
acute, 61. 
diagnosis of, 66. 
prognosis of, 66. 
symptoms of, 62, 
terminations of, 63. 
chronic, 66. 
centripetal march of, 67. 
of, 67. 
prognosis of, 68. 
symptoms of, 66. 
Neuritis, constitutional treatment 
of, 72. 
counter-irritants in, 73. 
difficult to cause in animals, 61. 
pathology of, 69. 
sedatives in, 73. 
tendency towards centres, 317. 
Neuromata, 343. 
Neurotomy, 282. 
indications for, 284. 
operative procedure, 284. 
Neuro-physiologv, 30. 
of stumps, 343. 
Neuro-traumatic eruptions, 155. 
joint disease, 169. 
Norris, nerve wound, 165. 
Nott, 240, 361, 362. 
Nutrition of skin in nerve wounds, 
151. 
Ogle, Wm., wounds of sympathetic, 
321, 322. 
Ollier, difficulty in causing nerve 
compression by callus, 117. 
Paccinian corpuscles enlarged, 
owing to certain nerve lesions, 91. 
Pacini, corpuscles of, 19, 20, 21, 
number of, 21. 
Packard, case, 148, 360. 
case of pressure on sciatic, 122. 
Paget, 84. 
callus, pressure from, 118 
nerve section, cases of, 235. 
on glossy skin, 157. 
Pain as a symptom, 192. 
causes of, 193. 
effect of on mind, 196. 
from chemical change in tis- 
sues, 54. 
intermittency of, 195. 
localization of, 193. 
nerves of, 39 
of cancer, 194. 
of causalgia, 194. 
of inflamed nerves, 194. 
proportion of wounds in which 
it is felt, 136. 
rare, at moment of nerve 
wounds, 136. 
reference of, 193. 
relation of, to sleep, 195. 
remotely referred, 137. 
sense, 187. 
treatment of, 266, 270, 271. INDEX. 
375 
Paralysis of muscles from nerve 
wound, 205. 
from pressure, 131. 
Pare, Ambrose, 348. 
case of Charles IX., 88- 
Pathology, physiological, of nerve 
lesions, 56. 
Paulet, 239. 
Pearson, treatment of nerve wounds, 
233. 
treatment of neuralgia, 268. 
Peripheral lesions, how diagnosed, 
223. 
Phlyctsenula, 154. 
Pineo, P., exsection of nerve, 293. 
Plexus, 28. 
Portal, paralysis from accumulation 
of feces, 126. 
Pressure, amount of, destructive to 
nerve, 113. 
T>v tumors, 119. 
experiments on, 111. 
---forms of, 114. 
from callus, 116. 
from callus, rare, 118. 
inflammatory, 114. 
of cicatrices, 115. 
on nerves, from malposition, 
128. 
on nerves, from muscular 
spasm, 127. 
on nerves, thermal changes in, 
178. 
palsy frorp, not limited to nerve 
injured, 220. 
slow, on nerves, effects of, 222. 
Prognosis, 225. 
as to atrophy, 228. 
electric, 227. 
of acute neuritis, 66. 
relation of to form of lesion, 
225. 
when to be made, 226. 
Prothesis, 257. 
Punctured nerves, 232. 
Puncture of nerve, case of, 92. 
Quinine, failure of, to aid traumatic 
pain, 280. 
Quotidian, the constant type of 
traumatic neuralgia, 195. 
Rate of transmission of nerve force, 
43. 
in local lesions, 225. 
Rauber, corpuscles of Pacini, num- 
ber of, 21. 
Rayer, herpes from nerve injury, 
153. 
Raynaud, phlyctsenula from nerve 
lesion, 154. 
Reflected palsy, 220. 
Reflex acts, in the amputated, 346. 
Reflex paralysis from dislocation 
of humerus, 98. 
Regeneration of nerves, 79. 
Rest, absolute, needed in neuritis, 
72. 
Rheumatism from spinal injuries, 
168. 
theories of, 170. 
Rheumatoid states from nerve le- 
sion, 168. 
Richardson on pain from nerve 
wounds, 136. 
Richel, 239. 
Robin, 77, 241. 
on neurilemma, 14. 
Rokitansky, pathology of neuritis, 
69. 
Romberg, neuro-traumatic erup- 
tions, 154. 
on pressure on nerves of neck, 
127. 
Samuel, theory of trophic nerves, 34. 
Sappey on neurilemma, 15. 
Schiff, date of reunion in nerves, 
235. 
on temperature after nerve sec- 
tion, 176. 
Schuh, 240. 
Schwann, sheath of, 16. 
composition of, 16. 
Sclerosis of nerves, 70. 
Scurvy, effect of on neuralgia, 280. 
Secretions, altered by nerve lesions, 
172. 
Section of nerve roots, results of, 74. 
of nerves, without loss of func- 
tion, 240. 
Sensation, alterations of, 179. 
early return of, 190, 191. 
fallacies as to, 184, 186. 
in lost limb, 352. 
lesion of, treatment, 265. 
loss of, usually incomplete, 187. 
most affected early in nerve 
wounds, 137. 
natural defect of in toes, 186. 376 
INDEX. 
Sensation, reference of, 48. 
why less injured than motion, 
188. 
Sense of locality, 185. 
muscular acts, 358. 
of pain, 187. 
of shortening in lost limbs, 351, 
352. 
Sensibility, how examined, 84, 182. 
of stumps, 344. 
prognosis as to, 227. 
Sensitive nerves, terminations of in 
skin, 18. 
Sensory hallucination after amputa- 
tion, 348. 
lesions, 179. 
counter-irritation in, 266. 
Shock, 138. 
cases of, 144. 
effects of, on motility, 140. 
proportion of cases feeling, 139. 
theory of, 139, 142, 144. 
Skin, change of, in partial nerve 
lesions, 152. 
nutrition of, how altered by 
nerve wounds, 151. 
Spasm, atropia in, 258. 
from rheumatism, 257. 
immediate, from nerve wound, 
138. 
of muscles, causing neuritis, 
343. 
local, 202. 
muscular, 203. 
treatment of, 257. 
Spinal palsy, diagnosis of, 223. 
Stewart, J. L., exsection of median, 
298. 
Stich, diagnosis of local paralyses, 
224. 
Stimulants, neural, 49. 
Stohrer, battery of, 248. 
Strieker, structure of nerves, 17. 
Strychnia, hypodermic injections of, 
251. 
in nerve lesions, 251. 
Stumps, chorea of, 363. 
influence on, of weather, 345. 
motility of, 347. 
motor phenomena in, 347. 
neuralgia of, 360. 
neuralgia of, treatment, 361. 
neural maladies of, 343. 
neuromata of, 343. 
neuro-physiology of, 343. 
Stumps, sensibility of, 344. 
Sutures in nerve wounds, 235. 
of nerves, 237, 238, 242. 
how to make, 242. 
Yulpian on, 242, 243. 
Swan, callus, pressure from, 118. 
on intermittent traumatic pain 
195. 
on lancet wounds of nerves, 89. 
on contusion, 96. 
wounds of small nerves, 89. 
Sweat, changes of, in nerve wounds, 
173. 
Sympathetic nerve, wound of, 318. 
pressure on, in labor, 124. 
Tactile corpuscles, 19. 
Temperature, after physiological 
sections of nerves, 176. 
Bernard on, 176. 
changes of, in nerve wounds, 
cause of, 175. 
fall of, in compression of nerves, 
178. 
in causalgia, 175. 
in nerve wounds, 255. 
range of, in nerve lesions, 174. 
rise of, after massage, 250. 
Tension, loss of muscular, in nerve 
sections, 150. 
Tetanus, 147. 
Theories of shock, Brown-Sequard, 
142. 
Thermal delusions as to lost limbs, 
353. 
Thermometer, how to use, 174. 
Tillaux, 236, 238. 
on diagnosis, 221. 
strength of nerves, 22, 23. 
Traumatic neuralgia, statistics of 
operations for, 288. 
Treatment, 229. 
of causalgia, 272. 
of chorea, 367. 
of contusion, 229, 230. 
of hypersesthetic states, 266. 
of incised wounds, 234. 
of joint diseases, 258, 259. 
of lancet wounds, 233. 
of neuralgia, 267. 
of pain, 270. 
of sensory lesions, 265. 
Tremor of muscles, 203. 
/'Trophic centres, 74. INDEX. 
-Trophic changes from nerve 
wounds, 38, 149. 
nerves, 31. 
argument against, 36. 
Bernard on, 31. 
discussion of, 32, 33, 34. 
nerves, injuries of, 31, 32. 
relation of spine and ganglia 
to, 35. 
'Tumors, pressure of on nerves, 119. 
Turpentine in neuralgia, 268. 
Ulcers, healing of, in palsied parts, 
154. 
Union, immediate in nerve wounds, 
235. 
Yalleix, sensitive points in neural- 
gia, 67. 
Vaso-motor nerves, 34. 
Vater, corpuscles of, 19. 
Yerneuil, 239. 
Yertigo, after freezing of a nerve, 60. 
Yulpian and Phillipeaux on nerve 
nutrition, 37. 
Yulpian, nerve suture, 243. 
on corpuscles of tact, 21. 
reunion of nerves, time of, 235. 
Waller, Aug., on temperature, in 
freezing of nerves, 177. 
on chilling of nerves, 55, 60. 
on degeneration of nerves, 74. 
on pressure on nerves, 107,110. 
Water-dressings in causalgia, 272. 
Weber on effects of irritation of 
sympathetic, 32. 
Whitlow, from nerve wounds, 33. 
Whitlows, 162. 
Wounds, healing of, in palsied 
parts, 153. 
by lancet of small nerves, 88. 
of nerves by lancet, treatment, 
233. 
of nerves, incised, 83. 
Wyman on physiological chiasms, 
27.