Treatment. — The treatment of a wound in which the presence of a nerve lesion is demonstrated by characteristic symptoms does not differ from that of any other,—including strict asepsis,— but the nerve-ends should, whenever pos sible, be sutured.
—An analysis of 117 cases, in which immediate suture of a divided nerve had been performed, led De Forest Willard to conclude that a good prognosis, not only of sensation, but also of motion, was thus afforded. The cases showed that clean end-to-end su ture and a careful freeing of the ends for some distance from cicatricial tissue af forded the best chance for a restoration of function. The best suture-material was found to be fine chromicized catgut, inserted, by means of a small, round needle, directly through the body and sheath of the nerve. Two sutures cross ing at right angles were usually advis able. During the healing process the part was completely at rest and the nerve relaxed when possible. Strict antisepsis is, of course, required. Stretching if the encls are not in contact may be resorted to. In 81 cases analyzed by Bowlby, 32 cases were entirely and 34 partially suc cessful, while only 14 did not progress satisfactorily. In all such cases the re parative process is exceedingly slow, and the patient should be carefully warned of this fact.
Case in which the two ends could not be brought together without too mite11 tension; so, after freshening the lower end, the bulbous portion of the upper end was split down the greater part of the way and sutured down to be united to the lower end, as in the figures on next page. Dunean (Clinical Jour., Dee. 21, '92).
—Suecess has also attended many cases in which nerve suture was performed long after the in jury: years in some instances. In a few, sensation, to say nothing of motion, had long disappeared. De Forest Willard also analyzed 132 cases: a sufficient number to demonstrate that the fears of tetanus entertained some years ago were groundless and that secondary suture of fered good hope of success, and should be attempted, even years after the accident. Repeated operations may ultimately suc ceed, and efforts to repair the results of injury should therefore be renewed. Restoration of function may take place many months after the operation, sen sation returning first. Though the distal
portion of a divided nerve rapidly degen erates, as does an interposed graft, trans mission of function is possible and re generation may take place both as regards sensation and motion. Strict antisepsis must prevail and the nerve well exposed, the limb being surrounded by an Es march bandage. The bulbous proximal end is easily found, but to reach the dis tal end the tissues must be slit along the course of the nerve. The bulbous end is cut off and a small piece (one quarter inch) of the distal also; the two ends are then stretched and united as in the case of immediate suture. Out of 73 eases, Bowlby's statistics only include 15 complete failures. Various methods of end-to-end suturing are shown on the following page.
in some cases the ends of the nerves cannot be brought together even in pri mary operations, owing to destruction of a portion of the nerve. A flap may then taken from the nerve, as shown in the aline \ed cut, and reflected over to tl'e other end of the nerve. Eeturn of ,eii,ation and cure in one year has been obtaim.d from this operation, but it of tt n fails.
Other measures proposed have been to shorten the limb by excising a piece of the bone: an operation hardly to be rec ommended. Better than it is the Despres method. which consists in splicing the distal end of the injured nerve into an adjoining nerve, by separating the fibres of the latter. When these measures do not ceed, nerve-grafting should be t tied.
many cases very early return of motion after transplantation may be due to vi carious' movements of other muscles than those formerly paralyzed. and not to a regeneration of the latter's nerve-supply Reuben Peterson (Amer. Jour. of Med Sciences, Apr., '99).
Contusion.
Contusion of a nerve, whatever its origin,—a blow, the pressure of a dis located or fractured bone, of badly padded crutches, malposition, forceps pressure during delivery, ctc., — pro duces mechanical lesions involving more or less laceration of the nerve-fibres, sometimes complicated with hmmor rhage into the nerve-substance. In se vere cases the myelin may be involved, and the nerve suffer local destruction.