I. Nerve Suture. By DR. HuGo KRAMER (Heidelberg). This study embraces twenty-two cases in which nerve suture was practised on divided musculospiral nine times, median eleven times, ulnar six times, and brachial plexus once. At the outset, attention is called to the criteria by which the success of neuror rhaphy should be judged. Thus, a return of sensation may be due to (sensibilite suplie Letievant) tactile impressions imparted to adjoining intact areas, or because of a free anastomosis of terminal nerve filaments. In like manner muscle function may be deemed restored, whereas compensatory muscles may be active, or a muscle may be innervated from two different sources, and, finally, anomalous innervation may coexist.
The percentage of successful restitution of sensation in twenty-seven instances amounted to 78 per cent. Analysis of the reports of various operators as to the relative merits of primary and secondary suture is seemingly in favor of the latter. This discrepancy is attributed to the infringements of asepsis unavoid ably incident to primary suture of infected wounds, in conse quence of which healing per primam, a sine qua non for nerve union, cannot result.
As to individual differences in the healing of enumerated nerves, chances seem to favor the musculospiral ; but, again, this disparagement disappears when instances of the simultaneous division of median and ulnar nerve are subtracted. Inasmuch as a larger wound, under these circumstances, means greater defect, increased chances of infection, and greater scar, with protracted healing, these must needs delay active motions, and therefore constitute factors unfavorably influencing restitutio ad integrum. As to the method of suture, better results attended direct suture, and no untoward effects marked the use of silk. Better functional restoration of muscles is to be looked for in those muscles nearest in relation with the central nerve stump and its subsequent growth. Associated division of tendons quite urally retards restoration of function. Contracture of nistic muscles and faulty postural position of the hand wise act adversely. As to return of sensation, Kramer holds that no change is effected in the area of altered sensibility from the time of its diminution to that of complete healing, and only the intensity of altered sensation seems to be bettered. Trophic disturbance characterized by glossy skin is in direct proportion to the intensity of the anaesthesia. Vasomotor disturbance was most marked when the median and ulnar nerves were divided. The best prognosis can be offered in injury to musculospiral nerve.
In concurrence with other observers be it said that no com plete restitutio ad integrum has been attained. At the most, what has been accomplished is that one or two muscles have been pre served, and this at times is a relatively great gain.
In conclusion, the author commends, where possible, pri mary nerve suture and immediate exercise of affected muscles as a routine. Beitriige zur klinischen Chirurgie, Band xxviii, Heft 3.