degree, that the nerve ruptured, but no change could be noted to take place at its spinal connection. The reverse of this, however, took place when the direction of the force was altered. Two openings were made on the arm, one just above the wrist, three centimetres square, on the flexor surface of the forearm, and the median nerve exposed. A second opening was made at the brachial plexus, and the nerve also exposed at that point; traction was then made upon it in the latter locality, and at once the nerve at the wrist opening could be seen to move considerably from its position. In other words, the centripetal stretching produces a material effect on the peripheral termination of the trunk. With reference to the last point, as to whether the power of the nerve as a conductor of sensibility is altered by stretching, after various experiments the following conclusions were noted, viz., that the nerve is only elastic and stretchable within certain limits, that the limits of normal elasticity correspond with the physiological limits of the motion of the human body, and that any attempts to stretch the nerve beyond these limits are followed by a rupture in its continuity. In the second of my reported cases, it will be noted that the lady was always better when the sciatic nerve was put fully upon the stretch, almost to its extreme physiological limits, viz., when she was on horseback, with her knee over the pommel of the saddle, in a state of flexion and abduction; the leg, also, in this position being flexed on the thigh, and muscular power exerted to hold the body firmly in the saddle during the movements of the horse. From these facts, it would appear that nerve stretching, carried beyond the ordinary elasticity of the nerve to a degree sufficient to separate the continuity of the primitive fasciculi, is at least one point in the rationale of the cure, or all events in the relief of the pain.

With reference to the amount of stretching required, the following were the results of interesting experiments reported by Vogt :-*

I. That slight stretching (once) of the trunk of the sciatic in decapitated frogs increased the reflex irritability of the respective extremity.

* Die Nerven-Dehnung, als operation in der chirurgischen Praxis. Leipzig. Vogel., 1877, page 5.

2. That a second stretching, following shortly upon the first, reduces the irritability.

3. That a third stretching, following the second, reduces the irritability far below the normal standard, though mechanical stimuli may still act.

4. That the centripetal fibres of the sciatic cannot be exposed to prolonged and forcible stretching without losing, partially or fully, their function.

From these, he lays down the axiom that "every severe stretching of a nerve trunk reduces its irritibility and its reflex power, in the region supplied by it; or, in other words, the mechanical irritation of stretching changes the mechanism of nervous activity."

The following is the list of published cases in which the operation of nerve stretching has been performed, as given by Dr. Paul Vogt, in his work on the subject:

I. Billroth (operation performed in 1869, published in 1872): Laying bare the sciatic nerve and examining it with the finger. Nothing abnormal was detected. The spasm of the leg, for which the operation had been undertaken, completely ceased within three months of the operation.

2. Von Nussbaum (operation 1872): Laying bare and stretching the brachial plexus, on account of an intense neuralgia, of spasmodic contractions, and loss of sensations of the muscles of the arm. This operation was most completely successful.

3. Gärtner (1872): Laying bare and stretching the brachial plexus, for a paralysis of thirty-four years' standing. The arm was greatly wasted and the fingers contracted.

4. Patruban (1872): Laying bare and stretching of the sciatic nerve for sciatica. Great amelioration.

5. Vogt (1874): Laying bare and stretching of the ulnar nerve for paralysis, in consequence of adhesions with nerve point. Cured.

6. Von Nussbaum (1875): Laying bare and stretching of the tibial and peroneal nerves in a case of reflex epilepsy. Complete

cure.

7. Callender (1875): Laying bare and stretching of the

* Monthly Abstract of Medical Science, November, 1877.

median nerve in the stump of a forearm, on account of neuralgia. Cured.

8. Von Nussbaum (1876): Laying bare and stretching the sciatic and crural nerves of both sides, for central disease. Paralysis of lower extremities with clonic spasms, following on a fall eleven years ago. Spasm entirely cured.

9. Vogt (1876): Laying bare and stretching the brachial plexus in traumatic tetanus following extensive injury to the hand. Cured.

10. Kocher (1876): Laying bare and stretching of the tibial nerve for traumatic tetanus.

II.

Petersen (1876): Laying bare and stretching of the tibial nerve for neuralgia.

12. Vogt (1876): Laying bare and stretching of the inferior dental, for neuralgia.

Cured.

Besides these Dr. Vogt gives three other cases of his own, each time for tetanus, and in two of the three cases the patients recovered. The following one of his cases may be cited to show the philosophy of the operation. The case was one of traumatic tetanus, following injury to the hand. (Case 9, cited above.) The patient was a man sixty-three years old, in whom tetanus had developed about two weeks after his receiving a severe lacerated wound of the right hand. In spite of local treatment and large doses of opiates, violent opisthotonos set in, with tonic rigidity of the back and lower extremities, with intercurrent clonic spasms. The wound had not thoroughly healed, but neither this nor any part of the arm or forearm was abnormally sensitive, while pressure over the region of the brachial plexus caused pain and a return of the tonic contractions of the muscles of the neck. Other treatment having been of no avail, and the cicatrix of the wound being in the vicinity of the median and radial nerves, it was decided to divide the cicatrix, detach the edges of the wound, excise these two nerves, and also stretch the brachial plexus. After the operation at the seat of the wound had been performed, the brachial plexus was exposed through a longitudinal cut at the anterior border of the trapezius, about two inches above the clavicle. The loops of the plexus were then raised upon the finger, drawn out, and thoroughly stretched in both directions. In the operation, the nerve sheaths, which were found to be quite

red, were freely divided. The wound was dressed with salicylicated jute, a drainage tube having been used to provide for free discharge. A short and violent attack of vomiting took place on the next day, but the recovery from the tetanic condition was immediate and complete. There was free use of the jaws, tongue, and throat, and neither the mobility nor the sensibility of the arm appeared to be appreciably affected. In about two weeks the patient went out completely cured.

In addition to the foregoing cases, I have found the following ones. Mr. John Chiene* records two cases of stretching the sciatic which are somewhat remarkable, in that the patients, immediately after the stretching, retained complete motor power. The first operation was performed on the 19th of April; the next day the pain had entirely disappeared. The patient was discharged on May 11, 1877. In the second case, the nerve was stretched on the 23d of April; the nerve substance appeared fatty, and its course was covered by a plexus of large and tortuous veins. In attempting to raise the limb from the table, it stretched to such a degree the operator supposed he had torn it. On the following day both sensation and motion were not affected, and the patient, as in the first case, expressed himself as not having been so comfortable for months. By the 10th of May he was cured. Now, in both my cases of sciatic stretching, motion was at first much impaired and only gradually restored; the pains were often intense, but not of the neuralgic character, and lasted for several days.

In the "Lancet," another case of sciatica is reported, which was treated by Dr. Macfarlane, of Kilmarnock, with success, by stretching the nerve. In this case the nerve was thoroughly extended, although the leg was not raised from the table. After eight months, there had been no return of the pain.

Duplay reported last December two cases of nerve stretching, in one of which the nerves thus treated were the median and the radial, the disease being paralysis; a cure rapidly followed.

The second case was a man aged twenty-six, who had been wounded at the wrist, where a small tumor appeared, which was

* Practitioner, June, 1877.

† Medical Record, December, 1878.

+ London Medical Record, Jan. 15, 1879.

excessively painful. The nerve was fully stretched, the tumor soon disappeared, the muscles regained their contractility, and the pain ceased.

In this country, as far as my present research has gone, but two cases of nerve stretching have been recorded. If there be others that are known to those who read this paper and are interested in the subject, the author will feel thankful to them if they will notify him where such reports may be found. If such diseases as traumatic tetanus and epilepsy have been cured by these operations, this department of surgery must be looked upon with great interest by every physician and surgeon of the present day.

Dr. Wm. C. Cox* reports the two cases alluded to as operated upon by Thomas G. Morton, M. D., of Philadelphia. The first case was one of neuralgia of the shoulder and arm, arising from an accidental wound, made by the sharp points of a pair of scissors entering the outer side of the right wrist. The patient was just convalescing from an attack of typhoid fever, and, although the wound had healed within two weeks, the pain in the forearm extended to the elbow and shoulder, and resisted all means used to procure relief. The accident occurred on Feb. 11, 1877, and on May 7 the operation was performed. The stretching was done by the forefinger, and the wound closed with silver sutures. The record, to which I desire to call special attention, because the symptoms are those which I have noted in three cases now reported, and which it is important to know, with reference to prognosis, thus continues: "The pain in the arm, after the effects of the ether had passed off, was intense, notwithstanding large doses of morphia, used hypodermically. A few days later an abscess formed in the upper part of the wound, which discharged through the opening near the wrist. For several weeks a feeling of numbness continued in the little and ring fingers and upon the outside of the hand, but gradually these symptoms disappeared. In a month the pain had ceased; sewing and writing still produced an ache, which was participated in by the whole arm and shoulder. This gradually diminished; but as

* American Journal of the Medical Sciences, Vol. LXXV. page 150.

†These italics are made use of here to note that time is often required to complete the cure after these operations.