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The importance of exact and detailed methods of evaluating nerve deficit, and the careful recording of all factors which might influence nerve recovery is emphasized. In our hands the plasma clot repair of nerves has seemed to offer definite advantages over other methods of repair. We believe that the unavoidable obstacles to successful employment of grafts limits their use to small nerves and peripheral branches. Gentle and prolonged stretching of the central stump may be the answer to bridging the gap of major trunks.

A percutaneous technique of recording evoked nerve action potentials is described. It permits the evaluation of progress of regeneration after nerve injury in man, before the regenerative process has reached the appropriate distal muscles. A recording electrode is introduced percutaneously in the vicinity of the nerve trunk, proximal to the lesion. The nerve is then stimulated at several distal points with a cutaneous contact electrode. The potentials resulting from stimulation of the mixed nerve are recorded centripetally. If they are of low amplitude, an electronic average is used. The point along the nerve where a response can no longer be elicited is found. It can be assumed that regenerative activity has progressed to this point. Serial studies then allow evaluation of the progress of regeneration.

Histological studies on nerve fibers distributed in the bone marrow of young dogs and young goats have been performed, using silver staining methods.1. The nerves to be distributed in the bone marrow enter the medullary cavity through foramina nutricia in the form of a bundle of mixed nerve fibers, consisting of myelinated and non-myelinated ones. They are divided into two groups, nonvascular independent nerves and vascular proper ones.In addition, there are other nerve fibers which enter the medullary cavity through HAVERSian canals.2. The non-vascular independent and the vascular proper nerves form primary plexuses jointly and then give rise to simpler secondary plexuses.3. There are no nerve cells in the primary and the secondary nerve plexuses.4. Such nerve fibers as derived from these nerve plexuses form non-branching free endings of sensory nerve fibers in the interstitial tissue and also form terminal networks of vegetative nerve fibers on the walls of blood capillaries and venous sinuses and in the interstitial tissue.5. It has been ascertained that no terminal network of vegetative nerve fibers envelops free cells directly. This confirmation is different from the result reported by TAKEYAMA, but agrees with that published by STOHR.

1. The results of repair of the sciatic nerve and of its main divisions have been analysed in a series of 118 cases, the patients having been under observation for three to eighteen years (average 11·7 years). 2. A result was satisfactory if there was some return of sensibility throughout the autonomous zone (the area of skin supplied exclusively by the damaged nerve) and if the more important muscles of the leg were capable of contraction against gravity and resistance. 3. When the whole of the sciatic nerve is damaged it is necessary to present the results separately for the lateral and medial popliteal divisions. 4. Of forty-seven cases of repair of the medial popliteal nerve 79 per cent showed useful motor and 62 per cent useful sensory recovery. In three out of four cases the correspondence between the degree of motor and of sensory recovery was fairly close. 5. Of seventy-two cases of repair of the lateral popliteal nerve 36 per cent showed useful motor and 74 per cent useful sensory recovery. The latter figure must be regarded with some reserve because sensory "recovery" in the lateral popliteal zone may be due to the ingrowth of nerve fibres from contiguous normally innervated skin. Thus it is not possible to correlate motor and sensory recovery. 6. In eighteen cases of repair of the posterior tibial nerve, there was useful sensory recovery in the sole in twelve. But although there was evidence of recovery in the plantar muscles in eleven cases it was functionally valueless. 7. In repair of the medial popliteal nerve the result was better if suture had been carried out early. In repair of the lateral popliteal nerve there was no evidence that delay was harmful; but the proportion of good results was so low (as judged by motor function alone, sensory recovery being often extraneous) that this exception to a general rule cannot be taken very seriously. 8. Gaps of up to twelve centimetres–estimated after resection of the damaged nerve ends–could be closed without difficulty by the usual technique, and the extent of the gap up to that limit had no influence on the prognosis. The closure of larger gaps, when the knee must be flexed beyond a right angle, is not compatible with good recovery because the post-operative stretching of the nerve causes serious intraneural damage. 9. Nerve grafting has given poor results in repair of the sciatic nerve.

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1. A study was made of functional and structural changes during degeneration of end-plates in the rat diaphragm after phrenic nerve section at two levels. 2. For 8–10 hr after cutting the nerve in the neck, all end-plates retain the ability to transmit impulses. During the following 8–10 hr, an increasing number of end-plates lose this ability so that after a total of about 20 hr, no end-plates can transmit. 3. Transmission failure occurs abruptly at most end-plates. This failure is usually accompanied by cessation of spontaneous miniature end-plate potentials (min.e.p.p.s), though in a few cases min.e.p.p.s persist after junctional transmission has failed. Several degenerating junctions were observed where the frequency of min.e.p.p.s was very low, suggesting an intermediate stage in min.e.p.p. failure. 4. The time of junctional failure depends on the length of the degenerating nerve stump. For each additional centimetre of nerve, failure is delayed about 45 min. 5. Changes in ultrastructure of nerve endings closely parallel those of function. For about 8–12 hr after cutting the nerve, nearly all end-plates appear normal. During the period when transmission is failing, some end-plates are clearly undergoing structural break-down. By the time functional failure is complete, all end-plates appear grossly abnormal. 6. During degeneration, the contents of the axoplasm undergo disruption and the nerve terminal breaks up into small fragments. In contrast, the Schwann cell appears to become very active and its processes extend into the synaptic cleft to surround fragments of the nerve terminal. Ultimately, the Schwann cell completely replaces the axon at the end-plate. 7. Increasing the length of the peripheral nerve stump delays the onset of structural break-down. Disruption of end-plates near the site of nerve entry into the muscle occurs before those farther away. 8. It is suggested that end-plate degeneration is triggered by a signal which passes from the site of injury to the nerve terminal. The duration of the period after transection when end-plates appear to be normal would then reflect the time required for this signal to travel the length of the isolated nerve stump.

The individual fiber of a peripheral nerve is composed of an axon or neurite, which is usually encased in a myelin sheath. Surrounding this is a protoplasmic envelope, the sheath of Schwann. These elements, the neurite, the myelin sheath, and sheath of Schwann, are neurogenic in origin (Fig. 1). The neurite is a prolongation of an individual nerve cell, while the sheath of Schwann is composed of a syncytium of cells which migrate out from the neural crest in early embryonic life (Harrison). The myelin sheath is supposedly a product of the nerve cell. The individual nerve fibers are embedded in connective tissue, the endoneurium, and are gathered into bundles enclosed by fibrous tissue, the perineurium. The entire nerve, consisting of these bundles of individual fibers, is overlaid by connective tissue, referred to as epineurium (Fig. 2). Tumors of the peripheral nerves were divided by Virchow, in 1863, into false neuromas, which include tumors of the nerve sheath, and true neuromas including growths arising from nerve fibers or nerve cells. Among the true neuromas are ganglioneuromas of the peripheral, spinal, and sympathetic nerves, and amputation neuromas, which are a combination of nerve fiber and sheath regeneration following the severing of a nerve trunk. Sporadic examples of neuro-epitheliomas of the peripheral nerves have been reported.

A new surgical method has been experimentally deviced by the present author for the end-to-end repair of injured facial nerve of guinea pigs.It needs no saying that the method used for the repair of injured nerve is essential in modem surgery. However, suture of injured nerve is so complicated especially in otolaryngological field of medicine that the results obtained are often unsatisfactory. It is, therefore. desirable that a simple and efficient method should be perfected which will always give satisfactory results. The method described in this paper will meet that purpose.The principle of this method consists in twining the pericapsular connective tissues of the facial, nerve. Namely, the pericapsular connective tissues were twined without using any suture material so as to bring the ends of the nerve into contact each other, and then the injured portion was fixed with surrounding tissues.Results and Consideration:1. Following the fixation above stated, the nerve axis was observed, to regenerate from the proximal end at the rate of 1 to 0.2mm per diem, and completely regenerated within 12 to 16 weeks.2. Implantation of dissected nerve trunk was also undertaken in addition to this method. The nerve axis regenerated within 16 to 24 weeks, and there seems to exist no appreciable relation, between the results and the quality of the material implanted.3. This method should be performed as immediately after the injury as possible in order to give a satisfactory result.4. The preferable points of this method were as follows, 1) Material used for repair was readily obtained.2) No serious foreign body reaction was brought forth.3) Satisfactory repair was undertaken without injuring the nerve axis with suture material.

The History of the Operation of Nerve Anastomosis The Early History of the Operative Treatment for Facial Palsy The Choice of the Nerve to Be Grafted to the Facial Nerve: 1. The Hypoglossal Nerve 2. The Descendens Noni Nerve 3. The Glossopharyngeal Nerve Stages in Recovery from Facial Palsy and the Reassumption of Control of the Facial Muscles by the Nerve Cells of the Rolandic Cortex Experimental Investigations: A. Experiments Since the Great War B. Experiments Carried Out at Laurelwood Since July, 1930: 1. Anastomosis Experiments 2. Division of the Nerve in the Fallopian Canal; Decompression 3. The Introduction of Nerve Grafts into the Fallopian Canal The History of Intratemporal Operations in Man: 1. Decompression of the Facial Nerve 2. Direct Suture or Apposition of the Ends of the Divided Nerve Without Displacement from the Canal 3. Displacement of the Nerve from the Canal; Removal of Damaged Portion and Suture Comments and Conclusions: The Operation of Choice: The Introduction of

Histological study of 40 animals after cutting the n. ischiadicus allowed us to draw following conclusions. On any level of nerve injury, the place of trauma eventually creates different injury levels of every single nerve fiber included in the nerve trunk. This phenomenon is due to the anatomic structure of peripheral nerves, consisting of the axial cylinders. There is a gradation of the regenerative ability of the traumatized neurons, which finds its expression in the fact that the further from the nerve cell body is located the trauma, the more readily and rapidly proceeds the reduction of the lost part. With the approach of the trauma level to the neuron, regeneration of the lost part is inhibited, slackened and may bring about the destruction of the nerve. Repeated trauma of the peripheral nerve decreases the regneration ability of the injured neurons, and brings about more intensive and irreversible phenomena in nerve cells. Regeneration of peripheral nerves is less complete and proceeds less rapidly.

An investigation is reported on the properties and quantitative distribution of mast cells in normal and sectioned peripheral nerve. A considerable number of mast cells has been found in the epineurial connective tissue in normal rats, as well as scattered mast cells in the endoneurium. After nerve section there was an about five-fold increase in the number of endoneurial mast cells throughout the distal part of the sciatic nerve.

F OR nearly 90 years experimental and clinical evidence has favored structural support about a nerve repair 7,~7 with a material that permitted direct and reproducible maximal axonal spanning without axonal disorganization or connective tissue build-up. Only during the past year has such a material become available. 4 This material, Silastic, formed into thin, elastic tubes was tested in chimpanzees against thicker tubes of the same material, wraps of millipore, collagen, or silicone, and against standard epineural suturing without wrapping. The results have been promising? However, ill-fitting tubes, regardless of the material, can strangulate a nerve anastomosis if too tight or fail to support it if too loose. 13 Therefore, establishing the best cuff dimensions, including such specifications as the proper ratio between the cross-section area of the nerve and the tube, became an important prerequisite to clinical trials. This report describes refinements in the technical details of nerve repair utilizing a Silastic cuff.

1. 1. The common peroneal, radial, and ulnar nerves are quite susceptible to injury in fractures of the long bones. 2. 2. The preliminary examination of a fracture case should include search for any evidence of peripheral nerve damage. 3. 3. In the manipulation of fractures and application of retentive apparatus, the location of the major nerve trunks should be borne in mind so that they will not be injured needlessly. 4. 4. In a series of twenty-five cases of peripheral nerve injury, the distribution was found to be as follows: Per Cent Common peroneal nerve 32 Radial nerve 20 Ulnar nerve 20 Sciatic nerve 8 Median nerve 8 Brachial plexus 8 Intercostal nerve 4

In retrospect, duct injuries have, for the most part, been considered quite separately with respect to methods of repair and these usually have been emphasized under two headings: (1) the immediate repair, and (2) repair of the duct with existing fistulas. With reference to the seventh nerve peripheral injuries these, too, have been considered for the most part as separate entities, notably by Furstenberg and Bunnell. With reference to Butler and Guinan's article in 1933, it is apparent that the catheter obstructed the lumen and it is quite possible that a fistulous opening alongside of the ostium was responsible for the successful repair of the wound minasmuch as no mention is made of the observation that secretion was coming from the ostmm. No mention is made of nerve injury or repair and it is possible that the horizontal wound in their case did not sever the nerve branches as is so common in the vertical wounds. Dr. T. G. Blocker recently stated that in the maxillofacial injuries in World War II involving the parotid duct, the ducts were repaired by conversion into internal fistula and peripheral facial nerve branches nearly always regenerated spontaneously. In all the above case reports no mention had been made of the study of the tributary distribution to the parotid duct with lipiodol and x-ray. It is the contention of the author that, while many cases of separate injury of the duct and facial nerve exist in consequence of injuries of a type, it is more than likely that if parotid duct injury exists peripheral nerve injury is also present and vice versa. If a lacerating, penetrating or avulsion injury involves the parotid duct, the buccal and zygomatic branches of the facial nerve will be involved. Further from the successful secondary repair by primary suture and graft exemplified in this case, the author believes that it is not necessary to convert external fistulas into internal fistulas as a method of repair, and believes that it is practicable to explore, isolate, resect and anastomose by primary suture as a method. That is better surgery in view of the nerve factors present. The author's case, after pathological resection and excision forty-three days subsequent to the primary injury, was successfully repaired despite the existence of a 30 mm. dehiscence in the duct proper and a 30 mm. dehiscence in the zygomatic branch of the facial nerve. The use of an indwelling No. 30 alloy steel wire dowel, which can be carried out through the cheek with no residual evidence of a puncture wound externally, creates a new dowel material as well as supplying a dowel unsurpassed in capillary and surface tension factor. The successful repair of the above case should nullify the opinions of those who elect to extirpate the parotid gland or destroy the gland by radiation when obstruction or fistulas exist. With reference to the nerve injury successful repair by suture and inlay nerve graft with the use of a Bunnell pull-out undulating suture, is a practical means of reinervation and regeneration of the peripheral branches of the facial nerve when involved. Contrary to many of the opinions expressed, the nerve twigs in the area anterior to the parotid gland measure approximately 1 to 1 1 2 mm . in diameter and by careful suture and inlay grafting successful repairs can be obtained. The method used in the author's case in which the dehiscence existed was to tie a B silk suture around the proximal and distal nerve endings to obtain the shortest diameter and a direct line continuity between the nerve endings. The next step was to resect one of the peripheral twigs of the cervicofacial nerve branch equal m length to the dehiscent area and lay the graft alongside of the the silk tract. A Bunnell undulating pullout suture was threaded through the distal end of the severed nerve, then through the graft and thence through the proximal end of the severed nerve. The silk link joining the severed ends was then removed and the nerve ends freshened by section. Where the approximation of the cut ends could be brought into continuity as in the buccal branch by mobilization from the perineural tissues, a similar Bunnell suture was utilized to facilitate reservation. The Bunnell suture is spliced through the central part of the nerve graft into the central part of the cleanly cut proximal and distal traumatized nerves. This method permits a short cut in the reinervation and reanimation of the muscles of the face and eliminates residual paralysis. Dr. Paul W. Cohen interpreted the x-ray findings of the author's case after lipiodol injections, as a cystic encapsulated swelling most likely an obstruction of the duct. Otherwise, an exudation of the parotid fluid into the subcutaneous tissues would have caused a fistula after forty days. It is significant that no injection could be made into Stenson's duct through the natural ostium showing that the distal end of the duct had been fibrosed. An injection of methylene blue had been made into the swollen cheek to observe the existence of fistula along the path of the duct. No elimination of secretion by fistula was noted and the cheek continued to swell. Frequent aspirations controlled the swelling; as much as two ounces of saliva had been collected in a few hours. The repair of external parotid fistulas by conversion into internal fistulas is an obsolete operation requiring no exceptional skill, is not anatomical, and is not comparable with surgical principles applied in general surgery in which the method of repair of fistulas is directed to the restoration of lumen continuity. Perhaps the neglect of parotid duct repairs is based upon the existence of six salivary glands so that when one gland or duct is put out of function only a proportionate amount of emphasis is placed upon its importance. However, the loss of the parotid gland, due to extirpation, because of obstruction, or atrophy from radiation therapy, will cause facial asymmetry and this is of paramount importance to the plastic surgeon, particularly when there is an associated peripheral nerve paralysis.

✓ Nerve cells histologically similar to the ganglionic cells of the trigeminal nerve were observed in the proximal part of the sensory root and in the motor root of the human trigeminal nerve. They were also seen in the sensory root of the trigeminal nerve of the dog. Counting of the nerve fibers showed doubling of the number of nerve fibers in the three divisions compared with the fibers in the sensory root adjacent to the trigeminal ganglion. There was also an increase in the number of fibers within the sensory root as it courses centrally, while a decrease was seen in the number of fibers in the proximal part of the motor root. Intermediate nerve bundles were seen leaving the motor root near the pons and joining the sensory root centrally. The fibers of the sensory root corresponding to each peripheral division maintained their specific location in the sensory root during the whole course centrally.

1. Stretching of the tibial nerve cut 2 centimetres above the ankle has been the subject of an experimental study in rabbits. 2. The effects on intraneural microcirculation, on vascular permeability, and on the barrier function of the perineurium have been analysed with the aim of determining the extent to which a divided nerve can be stretched without interfering with the process of repair. 3. The results obtained may prove valuable for understanding basic mechanisms and for establishing certain important limitations when end-to-end suture of a nerve trunk is performed under some degree of tension in man.

This study is based on an analysis of the results of 69 peripheral nerve injuries in the upper and lower extremities treated conservatively or operatively. The assessment of recovery was made according to the British (Highet) method.The following results were obtained.1) The type of injury was classified into three types-non-degeneration type, partial degeneration type and complete degeneration type—according to the results of motor and sensory functional examinations, nerve conduction test and electromyography.2) In the cases with complete degeneration type regardless of the cause of nerve injuries and with partial degeneration type due to open wounds, we shall explorate the lesion of injured nerves surgically to decide the indications for neurolysis or nerve repair.3) In some patients, with peripheral nerve lesions in continuity and moreover complete degeneration type, no-recovery was obtained.4) The following peripheral nerve lesions in continuity, that is, the nerve action potentials could not be evoked through the peripheral segment of injured nerve, and furthermore the contrast media in neurography could not be flowed through the lesion, should be performed the nerve repair.

Summary In 16 rabbits an approximately 1.5 cm segment of the sciatic nerve was excised from the right posterior extremity and implanted in the dissected left sciatic nerve. — The nerve segments were joined by adhesives. In 6 cases the clotting substances used were heterologous containing factor XIII. In 8 cases homologous clotting substances were employed. In both methods coagulation was produced with a bovine thrombin solution. Two animals served as controls; in these the nerve ends were joined by microsurgical sutures. — After periods of 40 and 80 days the animals were sacrificed. Electrophysiologic tests were carried out in vitro in 5 rabbits. These showed the regenerates to be fully functional. On histologic examination no evidence of graft rejection was found. Distal to the transplants satisfactory regeneration with beginning axon myelinization was seen in most of the cases. Apposition of the nerve segments was found to be superior when using heterologous clotting substances. In the controls loosening of nerve structure and marked proliferation of epineurial connective tissue were seen at the site of the microsurgical sutures.

There has been some discrepancy in the literature regarding the effects of ischemia on peripheral nerve conduction: Are the more slowly conducting fibers or the more rapidly conducting fibers more sensitive to an ischemic environment? A technique of studying the compound action potential (AP) from more than one segment of the in vivo canine tibial-sciatic nerve is described. The neuromuscular complex (terminal nerve fibers, synapse, or muscle) was most sensitive to ischemia. The more slowly conducting nerve fibers were more sensitive to ischemia than the more rapidly conducting fibers, as shown by the earlier deterioration of the slower AP compared with the faster AP along the total nerve segment. But when the proximal and distal segments of this total nerve segment were compared, the more rapidly conducting proximal nerve fibers closer to the central nervous system were more sensitive to ischemia than the more slowly conducting distal nerve fibers. Therefore it was hypothesized that both the higher velocity and the greater sensitivity to ischemia of the proximal nerve segments are related to the mutual neural environment of closely packed, adjacent nerve fibers before they branch from their trunk.

1. The endoneurium in a frog nerve is less abundant than in a mammalian nerve, but as in the latter it consists of an inner and an outer endoneurium. There is no evidence that either of these forms a complete envelope around single nerve fibres. 2. The frog nerve perineurium consists of a deep, continuous layer of squamous epithelium, and a superficial, collagenous layer. It is not a lamellated structure. In addition, one or two apparently incomplete cellular layers of a different character can often be distinguished within the perineurium over the trunk and the branches of the sciatic nerve, but not over the roots. 3. The frog nerve epineurium is composed of loose connective tissue of a rather indistinct nature. A layer of endothelial cells found on the surface of the nerve in the region of the roots is probably derived from the abdominal peritoneum. 4. The perineurium prevents the quick penetration of silver nitrate into the nerve bundle, and behaves as an inextensible, semi-permeable membrane when the nerve is placed into a hypotonic solution. 5. A solution of methylene blue injected into the nerve bundle does not escape to the surface rapidly unless a very high pressure is applied. 6. Effective desheathing involves removal of all the components of the perineurium. Cleaning of the nerve surface which removes all traces of epineural tissue does not affect the rate of penetration of electrolytes into the nerve. If the perineural epithelium is removed as well, there is a great increase in the apparent permeability of the nerve surface. 7. These facts confirm the hypothesis that the perineurium is a diffusion barrier which insulates and protects the nervous elements from the surrounding mesodermal tissues: this is in accordance with embryological evidence that the perineurium is ectodermal in origin.

Objective: Brachial plexus injuries (BPIs) are complex and challenging injuries that can result in significant loss of functions involved in the upper extremity. The purpose of this study is to provide useful guidance for the management of BPIs. Methods: Twenty-two patients who underwent intercostal nerve transfer (ICNT) only or ICNT with additional spinal accessory nerve transfer (SANT) by sural nerve graft interposition for traumatic BPIs from 2005 to 2014 were retrospectively studied. The Medical Research Council scale was used for outcome assessment. Follow-up was performed for at least 1 year to confirm neurological outcomes. Results: Seventy-seven percent of all patients gained motor grade improvements after surgery; however, patients of the combined surgery group, who underwent ICNT and SANT (mean=2.2), showed better motor grade scale improvements than patients of the single-operation group, who underwent only ICNT (mean=1.083) (p=0.030). Moreover, a mean time to surgery of less than 6 months resulted in better outcomes than a mean time to surgery of greater than 6 months. Reinnervation of the musculocutaneous nerve was demonstrated in 92.8% of the patients who underwent surgery within the first 6 months postinjury, in 40% of the patients with a delay of between 6 and 12 months, and none of the patients who underwent surgery after 12 months (p=0.004). Conclusion: This study validated that ICNT with SANT is more effective for reconstructing musculocutaneous nerves in patients with BPIs, along with the fact that surgery should be performed as soon as possible after injury at least 6 months.

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