ON THE RESTORATION OF COORDINATED MOVEMENTS AFTER NERVE-SECTION.1

448 the adhesions were detached bled so freely that it was necessary to put an elastic ligature tightly round the pedicle of the tumour. This controlled the bleeding. After separating all the adhesions peritoneal flaps were made from about two inches above the elastic ligature and the tumour (which weighed five pounds and six ounces) was then cut away. On loosening the elastic ligature the cut surface bled freely, but this was stopped by successive silk sutures passed rather deeply and tied as tightly as possible. The flaps of peritoneum were then sewn over the i-tump. The left Fallopian tube formed a hydrosalpinx and it was accordingly removed. The right uterine appendages were also removed with a view to check the development of other small fibroids. The body of the uterus in this case was not removed. A Keith’s drainage-tube was inserted and the rest of the abdomen was closed in the usual way. The patient did perfectly well. Some months after leaving the hospital she came up again to tell us that she continued quite well. CASE 9. Uter2cs enlarged by fibroids forming a tumour rising to two inches above the navel ; portion of the tumour firmly by adhesions in Dou.yLas’s pouch bulging down the posterior vaginal wall,. abdominal hysterectomy with intra-_peritoneal treatment of the stump;;good recovery.-A single woman, aged 29 years, was admitted into the London Hospital on August 8th, 1899. The patient was sent to me by my colleague, Dr. G. Schorstein. The patient was a Russian Jewess and could speak very little English, so that the history was obtained with some difficulty ’through an interpreter. She seemed to have had pain in the lower abdomen more or less for three years. The periods had lasted eight days and during the first three days she had lost a great deal of blood. Her pain was much worse during the period. I There had been no intermenstrual loss. believe the obvious enlargement of the abdomen was one cause of considerable concern to the patient. On examination a firm, rounded, irregular tumour was felt occupying the lower part of the abdomen and reaching to three fingers’ breadth above the umbilicus; it extended outwards some four inches from the middle line on each side. The tumour was fairly moveable from side to side but not vertically. Vaginal examination had to be made under anæsthesia as the hymen was perfect and did not admit the finger without tearing. The os uteri was very high up, about half an inch above the pubes and to the right ; it could only be felt by pressing down the tumoar. A hard convex portion of the tumour lay in the posterior fornix bulging down the posterior vaginal wall to within one and This mass, which a half inches of the vaginal orifice. evidently formed part of the abdominal tumour, was practically fixed. The sound could only be passed three inches. Operation was performed on August 18th, 1899. A large incision was made, which extended some three inches above the umbilicus. A large tumour was found in the fundus and posterior wall of the uterus extending well out to the sides, There so as to leave very little room for manipulation. was a second tumour almost distinct from the first growing from the posterior wall of the uterus and lying This in the pelvis to which it was firmly adherent. was the mass that had been felt lying in the posterior fornix on vaginal examination. There was also on the right side an ovarian tumour of the size of a goose’s On the left side the ovary was larger than normal egg. and slightly cystic. With great difficulty the upper part of the broad ligament was secured and divided on each side ; a peritoneal flap was reflected from the anterior wall of the uterus and the uterine arteries were tied. Owing to ,the tumour described as growing from the lower part of the posterior wall of the uterus being firmly adherent in the pelvis no posterior flap of peritoneum could be made in this The tumour in question was freed from its adhesions, case. leaving a rather extensive raw surface in the neighbourhood of Douglas’s pouch. It was not till after this step of the operation that the uterus could be drawn out of the wound. The uterus and fibroid tumour were removed at the level of the internal os. Both uterine appendages were removed with the tumour. The stump was covered as well as possible with the anterior flap of peritoneum, which had been cut long. A Keith’s tube was inserted and the rest of the wound, which measured seven inches in length, was closed as usual. The patient made a very good recovery and left the hospital on Sept. 19th. I have seen her once some months afterwards and she was then quite well.

fixed

Harley-street, W.

ON THE RESTORATION OF COORDINATED MOVEMENTS AFTER NERVESECTION.1 BY ROBERT

KENNEDY, M.A., D.Sc., M.D. GLASG.

well known that after reunion of a divided of suture function may return sooner or by later, and that not only does this restoration of function imply simple return of sensation and of the capacity of making voluntary movements, but the re-establishment of complete localisation of sensation and of courdination of movements. When it is remembered that the individual nerve-fibres are supposed to be paths between well-defined centres and peripheral endings it is clear that so perfect a restoration of function is in many respects remarkable. Thus in coapting a divided nerve it is not likely that this can be effected with so great accuracy that the corresponding ends of the divided nerve-fibres can be brought into apposition. It is more likely that in coapting the nerve most of the ends of the nerve-fibres which are brought into contact are ends which do not correspond ; and thus it would be expected that in the reunited nerve new paths for the nervous impulses would be established. And yet, despite this complexity of structure and of function, the reunited nerve seems to be as capable as before the division of subserving its functions. In suturing divided nerves, care is usually given to secure that the two segments are approximated as nearly as possible in their old relationship. Thus the perfect recovery of localised and coordinated function might be due to a majority of the fibres being thus placed in a position for union of corresponding ends to take place. To investigate this subject, three experiments were performed on dogs, the sciatic nerve being chosen. In two experiments the peripheral segment, before reunion by means of suture, was twisted so as to bring the maximum number of non-corresponding nerve-fibre ends into juxtaposition, while in the third experiment reunion was made as accurately in the old position as possible. The object of this was to ascertain (1) if the time taken for the first evidence of recovery of coordinated movements and the course of development of the same were identical or different in the two cases ; and (2) if the resulting cicatricial nerve segments showed microscopically any important differences in the arrangement of the nerve-fibres. In all three experiments, the animal being ansestbetised, the sciatic nerve was divided at the level of the trochanter; but in the first two, before coapting the two ends by suture, the peripheral segment was rotated to the extent of a semicircle. Thus, on coaptation, the fibres of one side of the central segment were brought into apposition with fibres with which formerly they did not connect-i.e., the fibres of the opposite side of the nerve. In the third experiment the nerve was divided at the same point and accurate coaptation in the old relationship was effected by suture. The following is the course which the experiments exhibited with reference to recovery of function. EXPERIMENT 1. Division of the sciatic nerve at the level of the trochanter; rotation of the peripheral segment to the extent of a semicircle and suture.-Until the seventh day after the operation the animal showed no sign of returning function. It walked on the limb which was supported by plaster-of-Paris bandages. The paw was left unsupported for examination purposes and until the seventh day while the animal walked on the limb the paw was dragged along the ground with the dorsal surface down. But on the seventh day the paw was first used normally in walking, the plantar surface being placed correctly on the ground. This was taken as evidence of returning coordinated movements. Frequently while walking the paw turned over and the animal rested on the dorsal surface, but on these occasions the normal position was voluntarily regained after a step or two. Restoration of localised sensation could not be ascertained, but undoubted evidence of sensation was obtained on the tenth day. On the fourteenth day the supporting plasterof-Paris splint was nmoved and the wound was found to be IT is

nerve

now

means

1

The research is published in extenso in the Transactions of the of Edinburgh, vol. xxxix., No. 27, 1899, and was communicated by Professor McKendrick.

Royal Society

449 healed. The animal then used the leg perfectly, almos restoration of function is due to the re-establishment of the always placing the plantar surface of the paw on the groun( old paths by decussation in the nerve cicatrix or to the correctly. By the nineteenth day the dog had practicallJ reunion of ends of nerve-fibres which do not correspond but completely recovered from the effects of the operation. Or which happen to be brought into apposition. 5. That in the fifty-fourth day the nerve was again exposed and was suturing a divided nerve no trouble need be taken to secure found to be united in the position in which it had beer that coaptation of the two segments is effected in the old sutured. Stimulation above, below, and on the seat oi relationship, the simple approximation of the two ends, no reunion gave the normal contractions in the muscles oj matter in what relationship, being all that is required. Glasgow. the leg.

EXPERIMENT 2. lJit’ision of the sciatic nene at the levei of the trochanter,.rotation of the peripheral segment to tllt

semicircle and sY-ture.-In a few days the A BRIEF REVIEW OF OUR KNOWLEDGE walking about on its splinted leg, but CONCERNING BACKWARD DISPLACEdragging the paw along the ground with the dorsal MENTS OF THE PELVIC ORGANS. surface down. On the seventh day it was first noticed of was the paw that the plantar surface correctly placed BY FREDERICK HOLME WIGGIN, M.D. and, although occasionally turning over on the dorsal surface, it was on these occasions voluntarily replaced in THE most frequent causes of displacements of the pelvic position after two or three steps. By the twenty-first day distinct evidence of sensation was exhibited and the recovery organs are injuries of the perineum occurring during of the normal use of the limb was practically complete. The childbirth and septic infection of the uterine tissues, physiological examination of the nerve on the thirtieth day generally due to one of three causes-namely, abortion, showed it to be united in the position in which it was sutured or the intra-uterine use of unsterilised instruand to have regained its normal irritability and conductivity. gonorrhoea, EXPERIMENT 3. Divisaorc of the sciatic nerve at the level of ments. Could these etiological factors be done away withtlie troo7tanter; accurate coaptation by s1lture in normal posi- and in time let us at least hope that they will be, for all of tioit -On the seventh day the animal first showed signs of them are either preventable or amenable to proper methods recovery of function, as for the first time it was then noticed of treatment-there would be little left for the gynethat it walked placing the plantar surface of the paw on the cologist to do, and womankind, to say nothing of mankind, ground. It was not, however, able voluntarily to re-adjust would be not only benefited but made happier thereby. As the paw when it happened to turn over with the dorsal anterior uterine displacements are seldom pathological we surface down. This power was, however, exhibited on the will pass them by and come at once to backward displacefollowing day. By the eleventh day evidence of sensation ments of the organ. These may be congenital or they was obtained and by the fourteenth day the recovery of may occur during early life as a result of an improper function was complete. On the forty-ninth day the physio- mode of life, of the use of improper clothing, of falls, logical examination showed that reunion of the nerve had blows, the lifting of heavy weights, and, I believe, more taken place both anatomically and physiologically. frequently still from neglect to empty the bladder at proper As regards recovery of function, therefore, these three intervals of time, the over-distension of this viscus tending experiments followed a practically identical course. The to push the uterine body backward. In married women the microscopic examination of the three sciatic nerves showed trouble is chiefly due to injuries of the perineum and inflamthe following characters. The central segments showed matory disorders of the uterus, tubes, and ovaries. Retrothe characters of the normal sciatic nerve, except in so flexion of the uterus occurs generally after the occurrence far that the lymphatic spaces were somewhat distended, thus of septic infection following an abortion or childbirth, and is accounting for the increased thickness of the nerve which frequently due to the fact that the convalescence following This character was maintained these conditions is not sufficiently prolonged. was macroscopically evident. The symptoms which patients complain of who are sufferto within five millimetres of the seat of section. The perifrom backward uterine displacements are backache, in no nerve. fibres in old ing any pheral segments agreed showing part examined either close to the seat of reunion or more or less severe, referred to the upper portion of the In their place sacrum, a feeling of weight extending down to the thighs, in the terminal divisions of the nerve. abundant young nerve-fibres with well-defined general bodily weakness, inability to stand long or walk far, were characters. Lying between the young nerve-fibres were pain at the top of the head and in the ovarian region, degenerated remains of the old fibres, showing that dysmenorrhcea, leucorrhcea, and frequently menorrhagia. The diagnosis must of course be finally made by means The cicatricial Wallerian degeneration had taken place. segments were also all three practically identical in struc- of a bimanual vaginal or rectal examination, with the ture. In no case could continuity of nerve-fibres from the patient in the dorsal position, the patient having first been central to the peripheral segment be traced in a single requested to empty her bladder. When the finger is introsection. The arrangement of the young fibres was very duced into the vagina if this condition exists the cervix irregular, the fibres running a very tortuous course and will be found to point either towards the symphysis pubis or showing, therefore, in the section cut in all directions. The to lie parallel to the long axis of the vagina instead of being sections closely resembled the appearance of a neuroma. at right angles to it, as it should. Often more useful The microscopic appearances of the seat of reunion leave it, information about the pelvic organs can be obtained by therefore, doubtful whether the restoration of function in means of a rectal examination than by a vaginal one, and in the two first cases was due to the re-establishment of the unmarried women it should always be first made. old paths for the nervous impulses by decussation in the The treatment of backward uterine displacements may be cicatrix, or to the production of new paths by connexion either by the use of mechanical supports or by operative The former method of treatment is less often made between non-corresponding ends of nerve-fibres. means. The conclusions from the physiological and histological used than it formerly was, as it is palliative rather than results of the experiments are : 1. That after section and curative. It is indicated only in those cases where the conimmediate coaptation of a nerve, restoration of con- dition is due to relaxation of the tissue and ligaments, or ductivity and of voluntary function may be Effected in a few where operative measures are contra-indicated or declined. days. 2. That this early restoration of conductivity need It should not be used in any case where there is a laceration not be the result of reunion of the old nerve-fibres-i.e., of the cervix or any inflammatory disease, past or present, of reunion by so-called first intention, or without Wallerian the uterus and its appendages, or where there is a prolapse degeneration, but may be the result of regeneration of young of one or both ovaries. If it is determined to adopt this line nerve-fibres in the peripheral segment. 3. That voluntary of treatment the patient should be placed in the knee-chest coordinated movements are regained equally soon, whether position, the posterior vaginal wall retracted, and the the two ends of the divided nerve are united as accurately cervix exposed by means of a Sims speculum. The cervix as possible, so as to bring the corresponding ends of is next-after having been washed off with a mercuric the nerve-fibres into contact as nearly as possible, or chloride solution of 1 in 4CCO - grasped by a double whether previously to reunion the peripheral segment is tenaculum forceps and drawn down. The fundus is next twisted so that when united to the central segment non pushed towards its proper position by means of uterine corresponding ends of the nerve-fibres are brought into dressing forceps in the jaws of which a piece of cotton is contact, 4. That in the latter case the microscopic examina- held. The organ having been returned as nearly as possible tion of the seat of reunion leaves it doubtful whether the to its proper position should be retained there by means extent

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