In peripheral paralyses after injuries, fractures, etc., we consider principally the primary and secondary neurorrhaphy, which will give excellent results even after some years. The nerve, if enveloped in callus and scar-tissue, must first be freed (neurolysis). Should it be severed in its continuity so that its union is impossible, we will have to try first a "suture h distance" (Vanlair, Vulpian), and then its graft ing upon the area of a sound nerve. When this also fails, we can resort to tenoplasties.
The paralyses of the plexus of the upper extremity (birth-palsies) occupy a special position. A lesion of the cervical roots during labor may cause a paralysis of the upper roots (type of Duchenne-Erb) as well as that of the lower roots together with the sympathetic branch (Klumpke). According to the investigations of Kennedy, which we can verify from six operated cases, we frequently find a crushing of the roots and the interposition of scar-tissue which renders the interruption of the current a permanent one. The first union of the fifth and sixth roots, the origin of the supraspinatus nerve, is exposed to injury most frequently in different positions of the arm, owing to its location between the first rib, clavicle, and transverse processes of the vertebne; this is the reason why these types of paralysis are so numerous. Kennedy, as well as the author, was able to get a restitution of function after several months by resection of the scar-tissue.
In one case, of a girl of six years, we were unable to find the supra spinatus nerve, which arises at this typical location, as it had been destroyed during birth. In this, as well as in another case, we succeeded
in removing the interfering contraction by an osteotomy below the sur gical neck and then rotating the humerus outwardt4, and thus improved the function of the arm (Figs. 1S3a, 1S3b).
Overstretching the fibres without any macroscopic sear-tissue may also lead to interruption of the current, and we will then observe that the sensitive fibres are the more resistant (see Compression of the spine, Spondylitis).
A boy of five years was tied by his brother to the horn of a cow with a rope around the right wrist and was thus dragged quite a distance. Without any visible external injuries the arm was paralyzed. On cut ting down upon the plexus and following it to the foramina vertebrarum we were not able to find any macroscopic change in the roots. The electrical irritability was gone. Sensibility was not entirely abolished.
Similar conditions were observed in an operated case of birth-palsy. But usually we will find the above described sear-tissue, which we resect, reunite the stumps, and get good results. When no scar is present, then we will, when the ease presents itself for an early operation, provide rein nervation of the nerve from a sound trunk (partial central implantation); in older cases we will do a total peripheral implantation of the paralyzed trunks into the sound ones after careful analysis of the paralysis.